1
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Chin KM, Gaine SP, Gerges C, Jing ZC, Mathai SC, Tamura Y, McLaughlin VV, Sitbon O. Treatment algorithm for pulmonary arterial hypertension. Eur Respir J 2024:2401325. [PMID: 39209476 DOI: 10.1183/13993003.01325-2024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 07/09/2024] [Indexed: 09/04/2024]
Abstract
Pulmonary arterial hypertension leads to significant impairment in haemodynamics, right heart function, exercise capacity, quality of life and survival. Current therapies have mechanisms of action involving signalling via one of four pathways: endothelin-1, nitric oxide, prostacyclin and bone morphogenetic protein/activin signalling. Efficacy has generally been greater with therapeutic combinations and with parenteral therapy compared with monotherapy or nonparenteral therapies, and maximal medical therapy is now four-drug therapy. Lung transplantation remains an option for selected patients with an inadequate response to therapies.
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Affiliation(s)
- Kelly M Chin
- Division of Pulmonary and Critical Care Medicine, UT Southwestern, Dallas, TX, USA
| | - Sean P Gaine
- Department of Respiratory Medicine, National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Christian Gerges
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Zhi-Cheng Jing
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Yuichi Tamura
- Pulmonary Hypertension Center, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Vallerie V McLaughlin
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
- Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Olivier Sitbon
- Department of Respiratory Medicine, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France
- Université Paris-Saclay, Le Kremlin-Bicêtre, France
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2
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Issard J, Fadel E, Dolidon S, Gerardin B, Fabre D, Mitilian D, Mercier O, Jevnikar M, Jais X, Humbert M, Brenot P. Balloon pulmonary angioplasty for proximal chronic thromboembolic pulmonary hypertension in patients ineligible for pulmonary endarterectomy. Pulm Circ 2024; 14:e12432. [PMID: 39234392 PMCID: PMC11372088 DOI: 10.1002/pul2.12432] [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: 06/06/2023] [Revised: 07/23/2024] [Accepted: 08/18/2024] [Indexed: 09/06/2024] Open
Abstract
Balloon pulmonary angioplasty (BPA) to treat chronic thromboembolic pulmonary hypertension (CTEPH) is generally reserved for distal obstruction precluding pulmonary endarterectomy (PEA) but can be used in patients with proximal disease who are at high surgical risk or refuse surgery. This single-center retrospective study compared BPA efficacy in patients with proximal versus distal CTEPH. Of the 478 patients, 36 had proximal disease, follow-up was 11.6 months and mean number of BPA 6. After BPA, PVR, and mean pulmonary artery pressure decreased significantly in the proximal and distal groups (from 6.5 to 4.0 WU and 39 to 31 mmHg and from 7.6 to 3.8 WU and 44 to 31 mmHg, respectively, p < 0.001 for all comparisons). NYHA class also improved significantly in both groups, from 3 to 2, whereas the 6-min walk distance, cardiac output, and serum NT pro-BNP showed significant improvements only in the distal group. Thus, when PEA for CTEPH is technically feasible but not performed due to severe comorbidities or patient refusal, BPA can produce significant hemodynamic improvements, albeit less marked than in patients with distal disease. Better patient selection to BPA might improve outcomes in patients with proximal disease who are ineligible for PEA.
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Affiliation(s)
- Justin Issard
- Thoracic Surgery Department Marie Lannelongue Hospital, GHPSJ Le Plessis Robinson France
| | - Elie Fadel
- Thoracic Surgery Department Marie Lannelongue Hospital, GHPSJ Le Plessis Robinson France
| | - Samuel Dolidon
- Thoracic Surgery Department Marie Lannelongue Hospital, GHPSJ Le Plessis Robinson France
| | - Benoit Gerardin
- Thoracic Surgery Department Marie Lannelongue Hospital, GHPSJ Le Plessis Robinson France
| | - Dominique Fabre
- Thoracic Surgery Department Marie Lannelongue Hospital, GHPSJ Le Plessis Robinson France
| | - Delphine Mitilian
- Thoracic Surgery Department Marie Lannelongue Hospital, GHPSJ Le Plessis Robinson France
| | - Olaf Mercier
- Thoracic Surgery Department Marie Lannelongue Hospital, GHPSJ Le Plessis Robinson France
| | - Mitja Jevnikar
- Pulmonology Department, Bicêtre University Hospital Assistance Publique-Hôpitaux de Paris Le Kremlin-Bicêtre France
| | - Xavier Jais
- Pulmonology Department, Bicêtre University Hospital Assistance Publique-Hôpitaux de Paris Le Kremlin-Bicêtre France
| | - Marc Humbert
- Pulmonology Department, Bicêtre University Hospital Assistance Publique-Hôpitaux de Paris Le Kremlin-Bicêtre France
| | - Philippe Brenot
- Thoracic Surgery Department Marie Lannelongue Hospital, GHPSJ Le Plessis Robinson France
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3
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Kayali SM, Dietz BE, Siddiq BS, Ghaly M, Owens TS, Khouzam RN. Chronic thromboembolic pulmonary hypertension and balloon pulmonary angioplasty - Where are we in 2024? Curr Probl Cardiol 2024; 49:102481. [PMID: 38401824 DOI: 10.1016/j.cpcardiol.2024.102481] [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: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 02/26/2024]
Abstract
Pulmonary endarterectomy (PEA) is the first-line treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, some patients with CTEPH are considered inoperable, and in the last decade, balloon pulmonary angioplasty (BPA) has emerged as a viable therapeutic option for these patients with prohibitive surgical risk or recurrent pulmonary hypertension following PEA. Numerous international centers have increased their procedural volume of BPA and have reported improvements in pulmonary hemodynamics, patient functional class and right ventricular function. Randomized controlled trials have also demonstrated similar findings. Recent refinements in procedural technique, increased operator experience and advancements in procedural technology have facilitated marked reduction in the risk of complications following BPA. Current guidelines recommend BPA for patients with inoperable CTEPH and persistent pulmonary hypertension following PEA. The pulmonary arterial endothelium plays a vital role in the pathophysiologic development and progression of CTEPH.
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Affiliation(s)
- Sharif M Kayali
- University of Tennessee Health Sciences Center, Department of Cardiovascular Medicine, Memphis, TN.
| | - Bernhard E Dietz
- University of Tennessee Health Sciences Center, Department of Internal Medicine, Memphis, TN
| | - Bilal S Siddiq
- University of Tennessee Health Sciences Center, College of Medicine, Memphis, TN
| | - Michael Ghaly
- Baptist Memorial Hospital - North Mississippi, Department of Internal Medicine, Oxford, MS
| | - Timothy S Owens
- University of Tennessee Health Sciences Center, College of Medicine, Memphis, TN
| | - Rami N Khouzam
- Interventional Cardiologist at the Grand Strand Medical Center, Myrtle Beach, SC; Professor, School of Medicine, University of South Carolina, Columbia SC; Professor, Edward Via College of Osteopathic Medicine, Blacksburg, VA; Professor, at the Mercer School of Medicine, Savannah, GA; Professor, University of Tennessee College of Medicine, Memphis, TN
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4
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Krigere A, Kalejs VR, Kaulins R, Rudzitis A, Bondare L, Sablinskis M, Lejnieks A, Kigitovica D, Kurzyna M, Skride A. The Initial Experience of Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension in Latvia. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:568. [PMID: 38674214 PMCID: PMC11052274 DOI: 10.3390/medicina60040568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 03/21/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024]
Abstract
Background: Treatment options for inoperable chronic thromboembolic pulmonary hypertension (CTEPH) or persistent pulmonary hypertension after pulmonary endarterectomy (PEA) include targeted medical therapy and balloon pulmonary angioplasty (BPA). BPA is an emerging treatment modality that has been reported to improve functional capacity, pulmonary hemodynamics, and right ventricular function. Reports from expert centers are promising, but more data are needed to make the results more generalizable. Materials and Methods: We conducted a prospective analysis of nine consecutive CTEPH patients who underwent balloon pulmonary angioplasty (BPA) sessions at Pauls Stradins Clinical University Hospital in Riga, Latvia between 1 April 2022 and 1 July 2023. We assessed World Health Organization (WHO) functional class, 6 min walk distance (6MWD), blood oxygen saturation (SpO2), brain natriuretic peptide (BNP) level at baseline and 3 months after the first BPA session. For two patients on whom repeated BPA sessions were performed, we additionally assessed cardiac output (CO), pulmonary vascular resistance (PVR), and mean pulmonary artery pressure (mPAP). Results: A total of 12 BPA procedures for nine patients were performed; repeated BPA sessions were performed for two patients. Our results show a reduction in BNP levels and improvement in WHO functional class, 6MWD, and SpO2 after the first BPA session. Improvement in 6MWD was statistically significant. Additionally, an improvement in pulmonary hemodynamic parameters was observed. Conclusions: Our data show that BPA is an effective interventional treatment modality, improving both the pulmonary hemodynamics and functional status. Moreover, BPA is safe and excellently tolerated.
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Affiliation(s)
- Anna Krigere
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
| | - Verners Roberts Kalejs
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
| | - Ricards Kaulins
- Department of Internal Diseases, Riga Stradins University, 1007 Riga, Latvia; (R.K.); (A.L.)
| | - Ainars Rudzitis
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
- Department of Internal Diseases, Riga Stradins University, 1007 Riga, Latvia; (R.K.); (A.L.)
| | - Liga Bondare
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
| | - Matiss Sablinskis
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
| | - Aivars Lejnieks
- Department of Internal Diseases, Riga Stradins University, 1007 Riga, Latvia; (R.K.); (A.L.)
- Department of Internal Diseases, Riga East Clinical University Hospital, 1038 Riga, Latvia
| | - Dana Kigitovica
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
- Department of Internal Diseases, Riga Stradins University, 1007 Riga, Latvia; (R.K.); (A.L.)
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Andris Skride
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
- Department of Internal Diseases, Riga Stradins University, 1007 Riga, Latvia; (R.K.); (A.L.)
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5
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Haner Wasserstein D, Frishman WH. Impact of Balloon Pulmonary Angioplasty on Right Ventricular Function in Patients With Chronic Thromboembolic Pulmonary Hypertension. Cardiol Rev 2023:00045415-990000000-00133. [PMID: 37607033 DOI: 10.1097/crd.0000000000000571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) can develop in some patients after an acute pulmonary embolism. The disease is characterized by the conversion of emboli into fibrotic thrombi that chronically impede normal circulation through the pulmonary arteries and increase pulmonary vascular resistance. Over time, this increases right ventricular (RV) afterload and strains the RV. The RV compensates by undergoing cardiomyocyte hypertrophy and RV dilation that can maintain stroke volume. However, these adaptations eventually decrease cardiac output and lead to right heart failure. Balloon pulmonary angioplasty has been developed as a treatment option for CTEPH by systematically disrupting thrombosed vessels and improving blood flow throughout the pulmonary circulation. This ultimately reverses the structural maladaptation's seen in CTEPH and improves RV function.
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Affiliation(s)
| | - William H Frishman
- Department of Medicine, New York Medical College/Westchester Medical Center, Valhalla, NY
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6
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Alamri AK, Shelburne NJ, Mayeux JD, Brittain E. Pulmonary Hypertension Association's 2022 International Conference Scientific Sessions Overview. Pulm Circ 2023; 13:e12182. [PMID: 36644322 PMCID: PMC9832865 DOI: 10.1002/pul2.12182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
The considerable progress made in recent years in the diagnosis, risk stratification, and treatment of pulmonary hypertension was highlighted during the most recent edition of the Pulmonary Hypertension Association Scientific Sessions, which was held in Atlanta, Georgia from June 9 to 11, 2022, with the theme: Vision for the PHuture: The Evolving Science and Management of PH. Content presented over the 3-day conference focused on scientific and management updates since the last sessions were held in 2018 and included didactic talks, debates, and roundtable discussions across a broad spectrum of topics related to pulmonary hypertension. This article aims to summarize the key messages from each of the session talks.
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Affiliation(s)
- Ayedh K. Alamri
- Department of MedicineUniversity of UtahSalt Lake CityUtahUSA,Department of Medicine, College of MedicineNorthern Border UniversityArarSaudi Arabia
| | - Nicholas J. Shelburne
- Division of Allergy, Pulmonary, and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jennalyn D. Mayeux
- Department of Medicine, Division of Pulmonary and Critical Care MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Evan Brittain
- Division of Cardiovascular MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
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7
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Akincioglu C, Mehta S. Nuclear imaging in chronic thromboembolic pulmonary hypertension: increasingly central to diagnosis and management. J Nucl Cardiol 2022; 29:3401-3404. [PMID: 35851646 DOI: 10.1007/s12350-022-03056-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 06/01/2022] [Indexed: 01/18/2023]
Affiliation(s)
- Cigdem Akincioglu
- Division of Nuclear Medicine, Department of Medical Imaging, University of Western Ontario, Schulich School of Medicine and Dentistry, London, ON, Canada.
| | - Sanjay Mehta
- Southwest Ontario Pulmonary Hypertension Clinic, London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University and Pulmonary Hypertension Association (PHA) of Canada, London, ON, Canada
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8
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Hyder SN, Chatterjee S, Aggarwal V. Percutaneous Treatments for Pulmonary Hypertension: Reviewing the Growing Procedural Role for Interventional Cardiology. Interv Cardiol Clin 2022; 11:293-305. [PMID: 35710284 DOI: 10.1016/j.iccl.2022.01.006] [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] [Indexed: 06/15/2023]
Abstract
Pulmonary arterial hypertension is a common and highly morbid medical problem resulting in elevated pulmonary arterial pressures and pulmonary vascular resistance. Medical therapies are costly, and not always well-tolerated. Surgical therapies such as pulmonary endarterectomy and lung transplantation are limited to a small subset of patients due to various patient, disease, or institutional factors. Over the past decade, there has been growing investigation into endovascular interventional therapies for patients with pulmonary hypertension such as balloon pulmonary angioplasty and pulmonary denervation. In this review, we describe the current status, future directions, and our recommendations on technical considerations with these therapies.
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Affiliation(s)
- S Nabeel Hyder
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan Medical School, 1500 East, Medical Center Drive, SPC 5860, Ann Arbor, MI 48109, USA
| | - Saurav Chatterjee
- Division of Cardiovascular Medicine, North Shore-Long Island Jewish Medical Centers, Northwell Health, Zucker School of Medicine, 270-05 76(th) Avenue, New Hyde Park, NY 11040, USA
| | - Vikas Aggarwal
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan Medical School, 1500 East, Medical Center Drive, SPC 5860, Ann Arbor, MI 48109, USA.
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9
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Martin-Suarez S, Loforte A, Cavalli GG, Gliozzi G, Botta L, Mariani C, Orioli V, Votano D, Costantino A, Santamaria V, Tassi S, Fiaschini C, Campanini F, Palazzini M, Rossi B, Barbera NA, Niro F, Manes A, Saia F, Dardi F, Galiè N, Pacini D. Therapeutic alternatives in chronic thromboembolic pulmonary hypertension: from pulmonary endarterectomy to balloon pulmonary angioplasty to medical therapy. State of the art from a multidisciplinary team. Ann Cardiothorac Surg 2022; 11:120-127. [PMID: 35433353 PMCID: PMC9012190 DOI: 10.21037/acs-2021-pte-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/02/2022] [Indexed: 08/26/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease with a very complex pathophysiology differing from other causes of pulmonary hypertension (PH). It is an infrequent consequence of acute pulmonary embolism that is frequently misdiagnosed. Pathogenesis has been related to coagulation abnormalities, infection or inflammation, although these disturbances can be absent in many cases. The hallmarks of CTEPH are thrombotic occlusion of pulmonary vessels, variable degree of ventricular dysfunction and secondary microvascular arteriopathy. The definition of CTEPH also includes an increase in mean pulmonary arterial pressure of more than 25 mmHg with a normal pulmonary capillary wedge of less than 15 mmHg. It is classified as World Health Organization group 4 PH, and is the only type that can be surgically cured by pulmonary endarterectomy (PEA). This operation needs to be carried out by a team with strong expertise, from the diagnostic and decisional pathway to the operation itself. However, because the disease has a very heterogeneous phenotype in terms of anatomy, degree of PH and the lack of a standard patient profile, not all cases of CTEPH can be treated by PEA. As a result, PH-directed medical therapy traditionally used for the other types of PH has been proposed and is utilized in CTEPH patients. Since 2015, we have been witnessing the rebirth of balloon pulmonary angioplasty, a technique first performed in 2001 but has since fallen out fashion due to major complications. The refinement of such techniques has allowed its safe utilization as a salvage therapy in inoperable patients. In the present keynote lecture, we will describe these therapeutic approaches and results.
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Affiliation(s)
- Sofia Martin-Suarez
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Antonio Loforte
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Giulio Giovanni Cavalli
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Gregorio Gliozzi
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Luca Botta
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Carlo Mariani
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Valentina Orioli
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Daniela Votano
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Antonino Costantino
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Valeria Santamaria
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Sara Tassi
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Costanza Fiaschini
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Francesco Campanini
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Massimiliano Palazzini
- Cardiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Barbara Rossi
- Cardiac Anaesthesia Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Nicolò Antonino Barbera
- Cardiac Anaesthesia Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Fabio Niro
- Cardiovascular Radiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Alessandra Manes
- Cardiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Francesco Saia
- Cardiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Fabio Dardi
- Cardiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Nazzareno Galiè
- Cardiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
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10
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Cannon JE, Jenkins DP, Hoole SP. Chronic thromboembolic pulmonary hypertension: a review of risk factors, management and current challenges. Expert Rev Cardiovasc Ther 2022; 20:35-43. [DOI: 10.1080/14779072.2022.2034499] [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] [Indexed: 10/19/2022]
Affiliation(s)
- JE Cannon
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - DP Jenkins
- Cardiothoracic Surgical Unit, Royal Papworth Hospital, Cambridge, UK
| | - SP Hoole
- Interventional Cardiology, Royal Papworth Hospital, Cambridge, UK
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11
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Boon GJAM, van den Hout WB, Barco S, Bogaard HJ, Delcroix M, Huisman MV, Konstantinides SV, Meijboom LJ, Nossent EJ, Symersky P, Vonk Noordegraaf A, Klok FA. A model for estimating the health economic impact of earlier diagnosis of chronic thromboembolic pulmonary hypertension. ERJ Open Res 2021; 7:00719-2020. [PMID: 34853780 PMCID: PMC8628742 DOI: 10.1183/23120541.00719-2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 06/14/2021] [Indexed: 11/06/2022] Open
Abstract
Background Diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH)
exceeds 1 year, contributing to higher mortality. Health economic
consequences of late CTEPH diagnosis are unknown. We aimed to develop a
model for quantifying the impact of diagnosing CTEPH earlier on survival,
quality-adjusted life-years (QALYs) and healthcare costs. Material and methods A Markov model was developed to estimate lifelong outcomes, depending on the
degree of delay. Data on survival and quality of life were obtained from
published literature. Hospital costs were assessed from patient records
(n=498) at the Amsterdam UMC – VUmc, which is a Dutch CTEPH
referral center. Medication costs were based on a mix of standard medication
regimens. Results For 63-year-old CTEPH patients with a 14-month diagnostic delay of CTEPH
(median age and delay of patients in the European CTEPH Registry), lifelong
healthcare costs were estimated at EUR 117 100 for a mix of treatment
options. In a hypothetical scenario of maximal reduction of current delay,
improved survival was estimated at a gain of 3.01 life-years and 2.04 QALYs.
The associated cost increase was EUR 44 654, of which 87% was
due to prolonged medication use. This accounts for an incremental
cost–utility ratio of EUR 21 900/QALY. Conclusion Our constructed model based on the Dutch healthcare setting demonstrates a
substantial health gain when CTEPH is diagnosed earlier. According to Dutch
health economic standards, additional costs remain below the deemed
acceptable limit of EUR 50 000/QALY for the particular disease
burden. This model can be used for evaluating cost-effectiveness of
diagnostic strategies aimed at reducing the diagnostic delay. This constructed model based on the Dutch healthcare setting can be used
for evaluating cost-effectiveness of diagnostic strategies aimed at reducing
the diagnostic delay of chronic thromboembolic pulmonary hypertensionhttps://bit.ly/35yXPM3
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Affiliation(s)
- Gudula J A M Boon
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert B van den Hout
- Dept of Biomedical Data Science - Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany.,Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Harm Jan Bogaard
- Dept of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Marion Delcroix
- Dept of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Menno V Huisman
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany.,Dept of Cardiology, Democritus University of Thrace, Xanthi, Greece
| | - Lilian J Meijboom
- Dept of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Esther J Nossent
- Dept of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Petr Symersky
- Dept of Cardiac Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Frederikus A Klok
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Center for Thrombosis and Hemostasis, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
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12
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Interventional Management of Chronic Thromboembolic Pulmonary Hypertension. Cardiol Clin 2021; 40:103-114. [PMID: 34809911 DOI: 10.1016/j.ccl.2021.08.009] [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: 11/21/2022]
Abstract
Chronic thromboembolic pulmonary hypertension is a distinct form of pulmonary hypertension characterized by the nonresolution of thrombotic material in the pulmonary tree; whenever feasible and safe, first-line treatment should be pulmonary thromboendarterectomy. In patients who are not operative candidates, balloon pulmonary angioplasty (BPA) has emerged as an effective treatment modality that results in improvements in functional class, symptoms, hemodynamics, 6-minute walk distance, and right ventricular and pulmonary artery mechanics. Careful attention to procedural technique and rapid identification and treatment of complications are critical for a successful BPA program.
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Kaulins R, Vitola B, Lejniece S, Lejnieks A, Kigitovica D, Sablinskis M, Sablinskis K, Rudzitis A, Kalejs RV, Skride A. Chronic Thromboembolic Pulmonary Hypertension Mimicking Acute Pulmonary Embolism: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e933031. [PMID: 34545058 PMCID: PMC8475734 DOI: 10.12659/ajcr.933031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Patient: Female, 68-year-old
Final Diagnosis: Chronic thromboembolic pulmonary hypertension (CTEPH)
Symptoms: Dsypnea
Medication:—
Clinical Procedure: —
Specialty: Cardiology
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Affiliation(s)
- Ricards Kaulins
- Department of Internal Diseases, Riga Stradiņš University, Riga, Latvia
| | - Barbara Vitola
- Department of Rare Diseases, Pauls Stradiņš Clinical University Hospital, Riga, Latvia
| | - Sandra Lejniece
- Department of Internal Diseases, Riga Stradiņš University, Riga, Latvia.,Department of Hematology, Riga East Clinical University Hospital, Riga, Latvia
| | - Aivars Lejnieks
- Department of Internal Diseases, Riga Stradiņš University, Riga, Latvia.,Department of Internal Diseases and Endocrinology, Riga East Clinical University Hospital, Riga, Latvia
| | - Dana Kigitovica
- Department of Internal Diseases, Riga Stradiņš University, Riga, Latvia.,Department of Rare Diseases, Pauls Stradiņš Clinical University Hospital, Riga, Latvia
| | - Matiss Sablinskis
- Department of Internal Diseases, Riga Stradiņš University, Riga, Latvia.,Department of Rare Diseases, Pauls Stradiņš Clinical University Hospital, Riga, Latvia
| | - Kristaps Sablinskis
- Department of Internal Diseases, Riga Stradiņš University, Riga, Latvia.,Department of Rare Diseases, Pauls Stradiņš Clinical University Hospital, Riga, Latvia
| | - Ainars Rudzitis
- Department of Internal Diseases, Riga Stradiņš University, Riga, Latvia.,Department of Rare Diseases, Pauls Stradiņš Clinical University Hospital, Riga, Latvia
| | | | - Andris Skride
- Department of Internal Diseases, Riga Stradiņš University, Riga, Latvia.,Department of Rare Diseases, Pauls Stradiņš Clinical University Hospital, Riga, Latvia
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Liu HY, Wu YJ, Huang SC, Liu CL, Hsu HH, Yu CJ. Experiences with pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension at multiple centers in Taiwan. J Formos Med Assoc 2021; 121:604-612. [PMID: 34373177 DOI: 10.1016/j.jfma.2021.07.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/03/2021] [Accepted: 07/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Of the types of pulmonary hypertension, chronic thromboembolic pulmonary hypertension (CTEPH) may be cured through pulmonary endarterectomy (PEA). In this study, we investigated patient experiences with PEA for CTEPH treatment in Taiwan. METHODS We retrospectively reviewed the records of patients who underwent PEA in two medical centers between January 2005 and December 2019. We measured the following outcomes: in-hospital complications, improvements in cardiac function and exercise capacity, survival using Kaplan-Meier analysis after PEA. RESULTS Twenty-seven patients (female: 17) with a mean age of 52.6 years underwent PEA. Pre-operatively, most patients were New York Heart Association functional class (NYHA FC) III (n = 19) and IV (n = 7). The mean periods from the onset of symptoms to diagnosis and from diagnosis to operation were 22.6 and 22.3 months, respectively. After PEA, mean intubation time, and length of intensive care unit and hospital stay were 9, 11, and 20 days, respectively. Most patients' NYHA FCs improved to I (n = 15) and II (n = 10). The mean 6-min walk test (6MWT) result improved by 60.5%. The in-hospital mortality, mean follow-up period, and 5- and 10-year overall survival rates were 3.7%, 77.0 months, 96.3%, and 84.3%, respectively. Furthermore, 5- and 10-year disease-specific survival rates were both 96.3%. CONCLUSION When pre-operative and post-operative statuses were compared, we found a significant improvement in NYHA FC and 6MWT distance. Our study also found a lower in-hospital mortality rate compared to other published studies, except compared to the newer data provided by the University of California, San Diego group.
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Affiliation(s)
- Hao-Yun Liu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yih-Jer Wu
- Department of Medicine, MacKay Medical College and Cardiovascular Center, MacKay Memorial Hospital, New Taipei, Taiwan
| | - Shu-Chien Huang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Lung Liu
- Division of Chest Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104, Taiwan; Department of Medicine, MacKay Medical College, New Taipei City 252, Taiwan; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei 114, Taiwan
| | - Hsao-Hsun Hsu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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15
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Colebank MJ, Qureshi MU, Rajagopal S, Krasuski RA, Olufsen MS. A multiscale model of vascular function in chronic thromboembolic pulmonary hypertension. Am J Physiol Heart Circ Physiol 2021; 321:H318-H338. [PMID: 34142886 DOI: 10.1152/ajpheart.00086.2021] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by recurrent or unresolved pulmonary thromboemboli, leading to perfusion defects and increased arterial wave reflections. CTEPH treatment aims to reduce pulmonary arterial pressure and reestablish adequate lung perfusion, yet patients with distal lesions are inoperable by standard surgical intervention. Instead, these patients undergo balloon pulmonary angioplasty (BPA), a multisession, minimally invasive surgery that disrupts the thromboembolic material within the vessel lumen using a catheter balloon. However, there still lacks an integrative, holistic tool for identifying optimal target lesions for treatment. To address this insufficiency, we simulate CTEPH hemodynamics and BPA therapy using a multiscale fluid dynamics model. The large pulmonary arterial geometry is derived from a computed tomography (CT) image, whereas a fractal tree represents the small vessels. We model ring- and web-like lesions, common in CTEPH, and simulate normotensive conditions and four CTEPH disease scenarios; the latter includes both large artery lesions and vascular remodeling. BPA therapy is simulated by simultaneously reducing lesion severity in three locations. Our predictions mimic severe CTEPH, manifested by an increase in mean proximal pulmonary arterial pressure above 20 mmHg and prominent wave reflections. Both flow and pressure decrease in vessels distal to the lesions and increase in unobstructed vascular regions. We use the main pulmonary artery (MPA) pressure, a wave reflection index, and a measure of flow heterogeneity to select optimal target lesions for BPA. In summary, this study provides a multiscale, image-to-hemodynamics pipeline for BPA therapy planning for patients with inoperable CTEPH. NEW & NOTEWORTHY This article presents novel computational framework for predicting pulmonary hemodynamics in chronic thromboembolic pulmonary hypertension. The mathematical model is used to identify the optimal target lesions for balloon pulmonary angioplasty, combining simulated pulmonary artery pressure, wave intensity analysis, and a new quantitative metric of flow heterogeneity.
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Affiliation(s)
- Mitchel J Colebank
- Department of Mathematics, North Carolina State University, Raleigh, North Carolina
| | - M Umar Qureshi
- Department of Mathematics, North Carolina State University, Raleigh, North Carolina
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Richard A Krasuski
- Department of Cardiovascular Medicine, Duke University Health System, Durham, North Carolina
| | - Mette S Olufsen
- Department of Mathematics, North Carolina State University, Raleigh, North Carolina
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16
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Lloji A, Hooda U, Sreenivasan J, Malekan R, Aronow WS, Lanier GM. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2021; 11:330-347. [PMID: 34322303 PMCID: PMC8303037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/08/2021] [Indexed: 06/13/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary hypertension (PH) caused by thromboembolic disease with the secondary remodeling of the pulmonary vessels. The primary treatment of CTEPH is pulmonary thromboendarterectomy (PTE). However, some patients are not candidates for PTE because of surgically inaccessible thrombi or high operative risk and can be candidates for balloon pulmonary angioplasty (BPA), an emerging, lower risk treatment. This review discusses the patient selection, the technique, and comprehensive review of reported outcomes following BPA. BPA techniques have improved over the years, and so has its safety profile. Recent data show that after several sessions of BPA, patients who were not eligible for PTE had improvement in their hemodynamic profile, functional capacity, and 6-minute walk distance. Studies have shown that compared to riociguat, BPA has shown significant improvement in the functional capacity and hemodynamic measurements. Reperfusion pulmonary edema is a common complication after PTE and BPA, which may be due to vessel injury rather than pulmonary extravasation. Rates of complications have decreased especially after the use of optical coherence tomography, which helps in proper sizing of the balloons. Patients with CTEPH who are ineligible for PTE should be evaluated for BPA. In addition to medical therapy, BPA has shown promising clinical and hemodynamic outcomes in patients with CTEPH.
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Affiliation(s)
- Amanda Lloji
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
| | - Urvashi Hooda
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
| | - Jayakumar Sreenivasan
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
| | - Ramin Malekan
- Division of Cardiothoracic Surgery, Westchester Medical Center, New York Medical CollegeValhalla, New York, The United States
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
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17
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Mahmud E, Patel M, Ang L, Poch D. Advances in balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. Pulm Circ 2021; 11:20458940211007385. [PMID: 34104421 PMCID: PMC8150503 DOI: 10.1177/20458940211007385] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/14/2021] [Indexed: 11/17/2022] Open
Abstract
Balloon pulmonary angioplasty (BPA) is an emerging treatment option for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who have inoperable, segmental/subsegmental disease, or residual disease after pulmonary endarterectomy. In the past decade, advances in the techniques for BPA have led to better clinical outcomes with improvements in hemodynamics, pulmonary perfusion, exercise tolerance, functional capacity, and quality of life. We present the experience with BPA at our university, the largest CTEPH center in the world, followed by reviewing the published data regarding the efficacy and safety of BPA in patients with CTEPH. There is increasing evidence to support that the initial hemodynamic improvement is sustained for ≥3 years after the procedure. Although infrequent, complications observed with BPA are associated with pulmonary vascular injury or rarely reperfusion pulmonary edema. As the technique for percutaneous pulmonary artery revascularization has improved, the procedural risk and complications have continued to decrease. This promising technique continues to develop, and future research is required to demonstrate the long-term benefits of BPA, standardize the technique, and define a uniform institutional infrastructure for providing BPA as a part of the treatment of CTEPH.
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Affiliation(s)
- Ehtisham Mahmud
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA
| | - Mitul Patel
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA
| | - Lawrence Ang
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA
| | - David Poch
- Division of Pulmonary Critical Care Medicine, University of California San Diego, La Jolla, CA, USA
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18
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Martínez-Santos P, Velázquez-Martín MT, Barberá JA, Fernández Pérez C, López-Meseguer M, López-Reyes R, Martínez-Meñaca A, Lara-Padrón A, Domingo-Morera JA, Blanco I, Escribano-Subías P. Hipertensión pulmonar tromboembólica crónica en España: una década de cambio. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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19
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Coghlan JG, Rothman AM, Hoole SP. Balloon Pulmonary Angioplasty: State of the Art. ACTA ACUST UNITED AC 2021; 16:e02. [PMID: 33664801 PMCID: PMC7903587 DOI: 10.15420/icr.2020.14] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/01/2020] [Indexed: 12/14/2022]
Abstract
Balloon pulmonary angioplasty (BPA) is a novel technique for the treatment of chronic thromboembolic pulmonary hypertension. While cardiologists need no introduction to the concept of balloon angioplasty, BPA has its own particular challenges. This article aims to provide the reader with an overview of BPA, starting with an introduction to chronic thromboembolic disease (CTED), the standard management of chronic thromboembolic pulmonary hypertension (CTEPH), technical challenges faced when performing BPA and the evidence base supporting its use. The second part of the article will focus on the future of BPA, in particular the areas where research is required to establish an evidence base to justify the role of BPA in CTEPH and CTED treatment.
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20
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Chen ZW, Wu CK, Kuo PH, Hsu HH, Tsai CH, Pan CT, Hwang JJ, Ko CL, Huang YS, Ogo T, Lin YH. Efficacy and safety of balloon pulmonary angioplasty in patients with inoperable chronic thromboembolic pulmonary hypertension. J Formos Med Assoc 2021; 120:947-955. [DOI: 10.1016/j.jfma.2020.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/26/2020] [Accepted: 09/20/2020] [Indexed: 01/09/2023] Open
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21
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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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22
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Boon GJAM, Bogaard HJ, Klok FA. Essential aspects of the follow-up after acute pulmonary embolism: An illustrated review. Res Pract Thromb Haemost 2020; 4:958-968. [PMID: 32864549 PMCID: PMC7443426 DOI: 10.1002/rth2.12404] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 12/31/2022] Open
Abstract
Care for patients with acute pulmonary embolism (PE) involves more than determination of the duration of anticoagulant therapy. After choosing the optimal initial management strategy based on modern risk stratification schemes, patients require focused attention aimed at prevention of major bleeding, identification of underlying (malignant) disease, prevention of cardiovascular disease, and monitoring for long-term complications. The most frequent complication of PE is the so-called "post-PE syndrome," a phenomenon of permanent functional limitations after PE occurring in up to 50% of patients. The post-PE syndrome is caused by persistent deconditioning, anxiety, and/or ventilatory or circulatory impairment as a result of acute PE. The most severe and most feared presentation of the post-PE syndrome is chronic thromboembolic pulmonary hypertension (CTEPH), a deadly disease if it remains untreated. While CTEPH may be successfully treated with pulmonary endarterectomy, balloon pulmonary angioplasty, and/or pulmonary hypertension drugs, the major challenge is to diagnose CTEPH at an early stage. Poor awareness for the post-PE syndrome and in particular for CTEPH, high prevalence of persistent symptoms after PE and inefficient application of diagnostic tests in clinical practice all contribute to an unacceptable diagnostic delay and underdiagnosis. Its consequences are dire: increased mortality in patients with CTEPH, and excess health care costs, higher prevalence of depression, more unemployment and poorer quality of life in patients with post-PE syndrome in general. In this review, we provide an overview of the incidence and impact of the post-PE syndrome, and illustrate the clinical presentation, optimal diagnostic strategy as well as therapeutic options.
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Affiliation(s)
- Gudula J. A. M. Boon
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary DiseasesInstitute for Cardiovascular Research (ICaR‐VU)Amsterdam University Medical Centerlocation VUmcAmsterdamThe Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
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23
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Martínez-Santos P, Velázquez-Martín MT, Barberá JA, Fernández Pérez C, López-Meseguer M, López-Reyes R, Martínez-Meñaca A, Lara-Padrón A, Domingo-Morera JA, Blanco I, Escribano-Subías P. Chronic thromboembolic pulmonary hypertension in Spain: a decade of change. ACTA ACUST UNITED AC 2020; 74:384-392. [PMID: 32654945 DOI: 10.1016/j.rec.2020.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 05/25/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND OBJECTIVES Chronic thromboembolic pulmonary hypertension (CTEPH) treatment has evolved in the last decade. However, there is scarce information on the long-term impact of this progress in a real-life population at a national level. This study was designed to analyze the characteristics of CTEPH patients in Spain over the last decade. METHODS We prospectively collected epidemiological, clinical, and prognostic data from CTEPH patients consecutively included in the Spanish REHAP registry from January 1, 2007, to December 31, 2018. We evaluated differences over time, establishing 2013 as the reference date for analysis. Propensity scores for interventional treatment were calculated using a multivariable logistic regression model. RESULTS A total of 1019 patients were included; 659 (64.4%) were evaluated at a national CTEPH center. Overall, 350 patients (34.3%) were selected for surgery and 97 (9.6%) for percutaneous treatment. Patients diagnosed between 2007 and 2012 died more frequently than those diagnosed from 2013 onward (HR, 1.83; 95%CI, 1.07-3.15; P=.027). Within the subgroup of patients adjusted by propensity score, baseline pulmonary vascular resistance and the 6-minute walk test distance also determined the outcome (HR, 1.24; 95%CI, 1.15-1.33; P=.011; and HR, 0.93; 95%CI, 0.90-0.97; P=.001, respectively). High survival rates were found in patients who underwent an invasive procedure (pulmonary endarterectomy or balloon pulmonary angioplasty). CONCLUSIONS CTEPH diagnosis and prognosis have consistently improved in the last decade. Baseline disease severity determines the risk profile. Patients who undergo pulmonary endarterectomy or balloon pulmonary angioplasty have better outcomes.
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Affiliation(s)
- Paula Martínez-Santos
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
| | | | - Joan Albert Barberá
- Servicio de Neumología, Hospital Clínic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain; Servicio de Neumología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Manuel López-Meseguer
- Servicio de Neumología, Hospital Universitario Vall d'Hebron, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | | | - Amaya Martínez-Meñaca
- Servicio de Neumología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Antonio Lara-Padrón
- Servicio de Cardiología, Hospital Universitario de Canarias, Sta. Cruz de Tenerife, Spain
| | | | - Isabel Blanco
- Servicio de Neumología, Hospital Clínic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Pilar Escribano-Subías
- Unidad de Hipertensión Pulmonar, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
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24
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Abstract
PURPOSE OF REVIEW The present review provides an update on treatment of chronic thromboembolic pulmonary hypertension (CTEPH), a rare form of pulmonary hypertension characterized by precapillary pulmonary hemodynamic parameters with chronic thrombotic occlusion of the pulmonary vasculature. RECENT FINDINGS Pulmonary thromboendarectomy (PTE) remains the recommended treatment for patients with surgically accessible disease. Recent data suggest that patients preoperatively bridged with medical therapy may have improved outcomes but further research is needed. Riociguat improves hemodynamics, right ventricular function, quality of life, and functional capacity and is the drug of choice for patients with inoperable/persistent disease. Recently published data suggest that endothelin receptor blockers and treprostinil may also have a role in medical management of this patient population. A growing body of evidence indicates that in experienced centers balloon pulmonary angioplasty (BPA) may be a well tolerated and effective adjunct to pharmacological treatment for patients with inoperable disease affecting subsegmental vasculature. SUMMARY Untreated CTEPH carries significant morbidity and mortality. Recent publications provide a wealth of data on safety and efficacy of BPA for inoperable subsegmental disease, but its precise fit in the treatment algorithm, both pharmacological and procedural, requires further investigation. PTE remains the procedure of choice for surgically accessible disease.
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25
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Jin Q, Zhao ZH, Luo Q, Zhao Q, Yan L, Zhang Y, Li X, Yang T, Zeng QX, Xiong CM, Liu ZH. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: State of the art. World J Clin Cases 2020; 8:2679-2702. [PMID: 32742980 PMCID: PMC7360712 DOI: 10.12998/wjcc.v8.i13.2679] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/28/2020] [Accepted: 06/10/2020] [Indexed: 02/05/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a complex chronic disease in which pulmonary artery stenosis or obstruction caused by organized thrombus can lead to increased pulmonary artery pressure and pulmonary vascular resistance, ultimately triggering progressive right heart failure and death. Currently, its exact mechanism is not fully understood. Pulmonary endarterectomy (PEA) has immediate effects with low perioperative mortality and satisfactory prognosis in experienced expert centers for CTEPH patients with proximal lesions. Nevertheless, 37% of patients are deemed unsuitable for PEA surgery due to comorbidities and other factors, and nearly half of the operated patients have residual or recurrent pulmonary hypertension. Riociguat is the only approved drug for CTEPH, although its effect is limited. Balloon pulmonary angioplasty (BPA) is a promising alternative treatment for patients with CTEPH. After more than 30 years of development and refinements, emerging evidence has confirmed its role in patients with inoperable CTEPH or residual/recurrent pulmonary hypertension, with acceptable complications and comparable long-term prognosis to PEA. This review summarizes the pathophysiology of CTEPH, BPA history and development, therapeutic principles, indications and contraindications, interventional procedures, imaging modalities, efficacy and prognosis, complications and management, bridging and hybrid therapies, ongoing clinical trials and future prospects.
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Affiliation(s)
- Qi Jin
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zhi-Hui Zhao
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Qin Luo
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Qing Zhao
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Lu Yan
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yi Zhang
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Xin Li
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Tao Yang
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Qi-Xian Zeng
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Chang-Ming Xiong
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zhi-Hong Liu
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
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Comparison of Balloon Pulmonary Angioplasty and Pulmonary Vasodilators for Inoperable Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review and Meta-Analysis. Sci Rep 2020; 10:8870. [PMID: 32483219 PMCID: PMC7264327 DOI: 10.1038/s41598-020-65697-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 03/09/2020] [Indexed: 01/20/2023] Open
Abstract
Treatment options for chronic thromboembolic pulmonary hypertension (CTEPH) that is not amenable to thromboendarterectomy or is recurrent/persistent after thromboendarterectomy (inoperable CTEPH) include pulmonary vasodilators or balloon pulmonary angioplasty (BPA). We compared efficacy and safety outcomes of BPA with or without pulmonary vasodilators to pulmonary vasodilator therapy alone in patients with inoperable CTEPH. Observational and randomized trial data reporting outcomes for >5 patients with inoperable CTEPH were sought. Single-arm random effects meta-analyses were performed. The primary outcome was change in six-minute walk distance (6MWD). Secondary outcomes included safety; World Health Organization functional class (WHO FC); and change in mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance (PVR), and cardiac index. Thirty-four studies with 1604 patients were eligible for analyses. Both treatments resulted in significant improvement in 6MWD (71.0 meters, 95% CI: 47.4–94.5 meters with BPA versus 47.8 meters, 95% CI: 34.5–61.2 meters with pulmonary vasodilators), PVR [−3.1 Wood Units (WU), 95% CI: −4.9 to −1.4 WU versus −1.6 WU, 95% CI: −2.4 to −0.8 WU] and mPAP (−14.8 mmHg, 95% CI: −18.2 to −11.5 mmHg versus −4.9 mmHg, 95% CI: −6.9 to −2.8 mmHg). Cardiac index was similar and most patients were WHO FC II and III after their respective interventions. More complications occurred in the BPA arm. In conclusion, BPA and pulmonary vasodilators both improve 6MWD and hemodynamics in patients with inoperable CTEPH. While BPA may offer greater functional and hemodynamic improvements, this technique carries the accompanying risks of an invasive procedure.
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Zhang X, Guo D, Wang J, Gong J, Wu X, Jiang Z, Zhong J, Lu X, Yang Y, Li Y. Speckle tracking for predicting outcomes of balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension. Echocardiography 2020; 37:841-849. [PMID: 32447819 DOI: 10.1111/echo.14709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/30/2020] [Accepted: 05/02/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Right ventricular (RV) function is a prognostic marker of chronic thromboembolic pulmonary hypertension (CTEPH). We used two-dimensional (2D) speckle-tracking echocardiography (STE) to evaluate the therapeutic effects of balloon pulmonary angioplasty (BPA) in CTEPH patients. METHODS A total of 46 CTEPH patients who underwent 2D STE before and after BPA were enrolled in this retrospective study. The following RV functional parameters were measured: tricuspid annular plane systolic excursion (TAPSE), right ventricular fractional area change (RVFAC), RV index of myocardial performance (RIMP), and free wall longitudinal strain (RVFWLS). Satisfactory BPA was defined as mean pulmonary arterial pressure (mPAP) <25 mm Hg or improvement in mPAP > 10 mm Hg after BPA. Patients were divided into two groups according to mPAP values: group I had satisfactory BPA outcomes; group Ⅱ had unsatisfactory BPA outcomes. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve was used to determine the optimal cutoff values and the ability of RVFWLS to predict successful BPA outcomes. RESULTS After BPA, SPAP measured by echocardiography (SPAPecho ) and RIMP decreased, but TAPSE, RVFAC, and RVFWLS increased. Before BPA, group Ⅰ had significantly better RV function than group Ⅱ. Multifactor logistic regression analysis identified RVFWLS as an independent factor associated with satisfactory BPA outcomes. The optimal cutoff value for RVFWLS in predicting satisfactory BPA outcomes was -12.2%. CONCLUSIONS Balloon pulmonary angioplasty improves RV function in CTEPH patients. RVFWLS is a valuable noninvasive tool with which to assess the treatment effects of BPA. CTEPH patients with lower RVFWLS may have limited benefit from BPA.
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Affiliation(s)
- Xinyuan Zhang
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Dichen Guo
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jianfeng Wang
- Department of Intervention, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Juanni Gong
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiaopeng Wu
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhe Jiang
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jiuchang Zhong
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing, China
| | - Xiuzhang Lu
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yuanhua Yang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yidan Li
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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Affiliation(s)
- Stephen P Hoole
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, UK
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Hoole SP, Coghlan JG, Cannon JE, Taboada D, Toshner M, Sheares K, Fletcher AJ, Martinez G, Ruggiero A, Screaton N, Jenkins D, Pepke-Zaba J. Balloon pulmonary angioplasty for inoperable chronic thromboembolic pulmonary hypertension: the UK experience. Open Heart 2020; 7:e001144. [PMID: 32180986 PMCID: PMC7046957 DOI: 10.1136/openhrt-2019-001144] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/17/2019] [Accepted: 12/13/2019] [Indexed: 12/27/2022] Open
Abstract
Objective Inoperable chronic thromboembolic pulmonary hypertension (CTEPH) managed medically has a poor prognosis. Balloon pulmonary angioplasty (BPA) offers a new treatment for inoperable patients. The national BPA service for the UK opened in October 2015 and we now describe the treatment of our initial patient cohort. Methods Thirty consecutive, inoperable, anatomically suitable, symptomatic patients on stable medical therapy for CTEPH were identified and offered BPA. They initially underwent baseline investigations including Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) quality of life (QoL) questionnaire, cardiopulmonary exercise test, 6 min walk distance (6MWD), transthoracic echocardiography, N-terminal probrain natriuretic peptide (NT pro-BNP) and right heart catheterisation. Serial BPA sessions were then performed and after completion, the treatment effect was gauged by comparing the same investigations at 3 months follow-up. Results A median of 3 (IQR 1-6) BPA sessions per patient resulted in a significant improvement in functional status (WHO functional class ≥3: 24 vs 4, p<0.0001) and QoL (CAMPHOR symptom score: 8.7±5.4 vs 5.6±6.1, p=0.0005) with reductions in pulmonary pressures (mean pulmonary artery pressure: 44.7±11.0 vs 34.4±8.3 mm Hg, p<0.0001) and resistance (pulmonary vascular resistance: 663±281 vs 436±196 dyn.s.cm-5, p<0.0001). Exercise capacity improved (minute ventilation/carbon dioxide production: 55.3±12.2 vs 45.0±7.8, p=0.03 and 6MWD: 366±107 vs 440±94 m, p<0.0001) and there was reduction in right ventricular (RV) stretch (NT pro-BNP: 442 (IQR 168-1607) vs 202 (IQR 105-447) pg/mL, p<0.0001) and dimensions (mid RV diameter: 4.4±1.0 vs 3.8±0.7 cm, p=0.002). There were no deaths or life-threatening complications and the mild-moderate per-procedure complication rate was 10.5%. Conclusions BPA is safe and improves the functional status, QoL, pulmonary haemodynamics and RV dimensions of patients with inoperable CTEPH.
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Affiliation(s)
- Stephen P Hoole
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, United Kingdom
| | - John G Coghlan
- Department of Cardiology, Royal Free Hospital, London, United Kingdom
| | - John E Cannon
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, United Kingdom
| | - Dolores Taboada
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, United Kingdom
| | - Mark Toshner
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, United Kingdom
| | - Karen Sheares
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, United Kingdom
| | - Andrew John Fletcher
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, United Kingdom
| | - Guillermo Martinez
- Department of Anaesthetics, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, United Kingdom
| | - Alessandro Ruggiero
- Department of Radiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, United Kingdom
| | - Nicholas Screaton
- Department of Radiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, United Kingdom
| | - David Jenkins
- Department of Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, United Kingdom
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, United Kingdom
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Karyofyllis P, Demerouti E, Papadopoulou V, Voudris V, Matsubara H. Balloon Pulmonary Angioplasty as a Treatment in Chronic Thromboembolic Pulmonary Hypertension: Past, Present, and Future. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020; 22:7. [DOI: 10.1007/s11936-020-0807-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Ikeda N. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. Cardiovasc Interv Ther 2019; 35:130-141. [DOI: 10.1007/s12928-019-00637-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/19/2019] [Indexed: 12/16/2022]
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Jin Q, Luo Q, Yang T, Zeng Q, Yu X, Yan L, Zhang Y, Zhao Q, Ma X, An C, Xiong C, Zhao Z, Liu Z. Improved hemodynamics and cardiopulmonary function in patients with inoperable chronic thromboembolic pulmonary hypertension after balloon pulmonary angioplasty. Respir Res 2019; 20:250. [PMID: 31703589 PMCID: PMC6842206 DOI: 10.1186/s12931-019-1211-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/10/2019] [Indexed: 12/16/2022] Open
Abstract
Background Balloon pulmonary angioplasty (BPA) has been demonstrated to improve cardiac function and exercise capacity in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH), but its instant impact on cardiopulmonary function has seldom been evaluated. This study aims to determine the safety and efficacy of BPA and its immediate and lasting effects on cardiopulmonary function among CTEPH patients. Methods From May 2018 to January 2019, patients with inoperable CTEPH who underwent BPA sessions were consecutively enrolled. Hemodynamics were measured by right heart catheterization, selective pulmonary angiography and BPA were successively conducted. Hemodynamic variables, WHO functional class (WHO-FC), 6-min walk distance (6MWD) and serum NT-proBNP were evaluated before and after BPA sessions during hospitalization. Pulmonary function testing (PFT) and cardiopulmonary exercise testing (CPET) were performed within 1–3 days pre and post BPA to evaluate the effect of BPA on cardiopulmonary function. Results Twenty-five patients with inoperable CTEPH who underwent a total of forty BPA sessions were consecutively enrolled. A total of 183 segmental or subsegmental vessels (4.6 ± 1.9 vessels per session) in 137 segments (3.4 ± 1.6 segments per session) were dilated. No procedure-related complications occurred. Instant hemodynamics, WHO-FC, 6MWD and NT-proBNP were all significantly improved after a single BPA session. Significant improvement in cardiopulmonary function was also evident as assessed by PFT indexes (forced vital capacity, forced expiratory volume in the first second, maximal voluntary ventilation) and CPET parameters (peak work rate, peak VO2, oxygen uptake efficiency slope). Further analysis among ten CTEPH patients receiving multiple BPA sessions (2–4 sessions) indicated BPA resulted in lasting improvements in hemodynamics and cardiopulmonary function. Conclusions BPA, a safe and effective approach, can bring instant improvements after a single session and lasting benefits after multiple sessions to hemodynamics and cardiopulmonary function for patients with inoperable CTEPH.
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Affiliation(s)
- Qi Jin
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Tao Yang
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Qixian Zeng
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Xue Yu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Lu Yan
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Yi Zhang
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Qing Zhao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Xiuping Ma
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Chenhong An
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Changming Xiong
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Zhihui Zhao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
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