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Skoro‐Sajer N, Sheares K, Forfia P, Heresi GA, Jevnikar M, Kopeć G, Moiseeva O, Terra‐Filho M, Whitford H, Zhai Z, Beaudet A, Gressin V, Meijer C, Tan YZ, Abe K. Treatment and management of chronic thromboembolic pulmonary hypertension (CTEPH): A global cross-sectional scientific survey (CLARITY). Pulm Circ 2024; 14:e12406. [PMID: 38947169 PMCID: PMC11214874 DOI: 10.1002/pul2.12406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 05/30/2024] [Accepted: 06/14/2024] [Indexed: 07/02/2024] Open
Abstract
Advances in the treatment of chronic thromboembolic pulmonary hypertension (CTEPH) over the past decade changed the disease landscape, yet global insight on clinical practices remains limited. The CTEPH global cross-sectional scientific survey (CLARITY) aimed to gather information on the current diagnosis, treatment, and management of CTEPH and to identify unmet medical needs. This paper focuses on the treatment and management of CTEPH patients. The survey was circulated to hospital-based medical specialists through Scientific Societies and other medical organizations from September 2021 to May 2022. The majority of the 212 respondents involved in the treatment of CTEPH were from centers performing up to 50 pulmonary endarterectomy (PEA) and/or balloon pulmonary angioplasty (BPA) procedures per year. Variation was observed in the reported proportion of patients deemed eligible for PEA/BPA, as well as those that underwent the procedures, including multimodal treatment and subsequent follow-up practices. Prescription of pulmonary arterial hypertension-specific therapy was reported for a variable proportion of patients in the preoperative setting and in most nonoperable patients. Reported use of vitamin K antagonists and direct oral anticoagulants was similar (86% vs. 82%) but driven by different factors. This study presents heterogeneity in treatment approaches for CTEPH, which may be attributed to center-specific experience and region-specific barriers to care, highlighting the need for new clinical and cohort studies, comprehensive clinical guidelines, and continued education.
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Affiliation(s)
- Nika Skoro‐Sajer
- Division of Cardiology, Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | | | - Paul Forfia
- Temple University HospitalPhiladelphiaPennsylvaniaUSA
| | | | | | - Grzegorz Kopeć
- Pulmonary Circulation Center Jagiellonian University Medical College, John Paul II Hospital in KrakowKrakowPoland
| | - Olga Moiseeva
- Almazov National Medical Research CenterSt. PetersburgRussia
| | - Mario Terra‐Filho
- Pulmonary Division, Heart Institute (Incor)University of Sao PauloSao PauloBrazil
| | | | - Zhenguo Zhai
- State Key Laboratory of Respiratory Health and Multimorbidity, Department of Pulmonary and Critical Care MedicineCenter of Respiratory Medicine, China‐Japan Friendship Hospital, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing ChinaBeijingChina
| | - Amélie Beaudet
- Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson & Johnson, Global Market AccessAllschwilSwitzerland
| | - Virginie Gressin
- Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson & Johnson, Global Medical AffairsAllschwilSwitzerland
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Caspersen CK, Ingemann-Molden S, Grove EL, Højen AA, Andreasen J, Klok FA, Rolving N. Performance-based outcome measures for assessing physical capacity in patients with pulmonary embolism: A scoping review. Thromb Res 2024; 235:52-67. [PMID: 38301376 DOI: 10.1016/j.thromres.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/22/2023] [Accepted: 01/10/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Up to 50 % of patients surviving a pulmonary embolism (PE) report persisting shortness of breath, reduced physical capacity and psychological distress. As the PE population is heterogeneous compared to other cardiovascular patient groups, outcome measures for assessing physical capacity traditionally used in cardiac populations may not be reliable for the PE population as a whole. This scoping review aims to 1) map performance-based outcome measures (PBOMs) used for assessing physical capacity in PE research, and 2) to report the psychometric properties of the identified PBOMs in a PE population. METHODS The review was conducted according to the Joanna Briggs Institute framework for scoping reviews and reported according to the PRISMA-Extension for Scoping Reviews guideline. RESULTS The systematic search of five databases identified 4585 studies, of which 243 studies met the inclusion criteria. Of these, 185 studies focused on a subgroup of patients with chronic thromboembolic pulmonary hypertension. Ten different PBOMs were identified in the included studies. The 6-minute walk test (6MWT) and cardiopulmonary exercise test (CPET) were the most commonly used, followed by the (Modified) Bruce protocol and Incremental Shuttle Walk test. No studies reported psychometric properties of any of the identified PBOMs in a PE population. CONCLUSIONS Publication of studies measuring physical capacity within PE populations has increased significantly over the past 5-10 years. Still, not one study was identified, reporting the validity, reliability, or responsiveness for any of the identified PBOMs in a PE population. This should be a priority for future research in the field.
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Affiliation(s)
| | - Stian Ingemann-Molden
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Anette Arbjerg Højen
- Department of Health Science and Technology, Aalborg University, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jane Andreasen
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Denmark; Department of Health Science and Technology, Aalborg University, Denmark; Aalborg Health and Rehabilitation Centre, Aalborg Municipality, Denmark
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Nanna Rolving
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Denmark; Department of Public Health, Aarhus University, Denmark.
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Dardi F, Rotunno M, Guarino D, Suarez SM, Niro F, Loforte A, Taglieri N, Ballerini A, Magnani I, Bertozzi R, Donato F, Martini G, Manes A, Saia F, Pacini D, Galiè N, Palazzini M. Comparison of different treatment strategies in patients with chronic thromboembolic pulmonary hypertension: a single centre real-world experience. Int J Cardiol 2023; 391:131333. [PMID: 37673403 DOI: 10.1016/j.ijcard.2023.131333] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 08/18/2023] [Accepted: 09/01/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Pulmonary endarterectomy (PEA) has been the most effective therapy for chronic thromboembolic pulmonary hypertension (CTEPH). However, there is a substantial proportion of patients deemed not operable in whom other treatment strategies are available: medical therapy and balloon pulmonary angioplasty (BPA). We aimed to compare different CTEPH treatment strategies effect in a real-world setting. METHODS All patients with CTEPH referred to our centre were included. We compare the short-term clinical, functional, exercise and haemodynamic effect of medical therapy (irrespective of subsequent treatment strategies), PEA and BPA (irrespective of previous/subsequent treatment strategies); we also describe the long-term outcome of the different patient groups. RESULTS We included 467 patients (39% were treated only with medical therapy, 43% underwent PEA, 13% underwent BPA and 5% were not treated with any therapy). Patients treated only with medical therapy were the oldest; compared to patients undergoing PEA, they had a lower exercise capacity, a higher risk profile and gained a lower haemodynamic, functional and survival benefit from the treatment. Patients undergoing BPA had a lower haemodynamic improvement but a comparable functional, exercise and risk improvement and a similar survival compared to patients undergoing PEA; their survival is anyway better than patients undergoing only medical treatment. Untreated historical control patients had the worst survival. CONCLUSIONS We confirm the superiority of PEA compared to any alternative treatment in CTEPH patients and we observe that BPA, in patients deemed not operable or with persistent/recurrent PH after PEA, leads to a better outcome than medical therapy alone.
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Affiliation(s)
- Fabio Dardi
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy.
| | - Mariangela Rotunno
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Daniele Guarino
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Sofia Martin Suarez
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy; Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Fabio Niro
- Radiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Antonio Loforte
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy; Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Nevio Taglieri
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Alberto Ballerini
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Ilenia Magnani
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Riccardo Bertozzi
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Federico Donato
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Giulia Martini
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Alessandra Manes
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Francesco Saia
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Davide Pacini
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy; Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Nazzareno Galiè
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Massimiliano Palazzini
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
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Guth S, Wilkens H, Halank M, Held M, Hobohm L, Konstantinides S, Omlor A, Seyfarth HJ, Schäfers HJ, Mayer E, Wiedenroth CB. [Chronic thromboembolic pulmonary hypertension]. Pneumologie 2023; 77:937-946. [PMID: 37963483 DOI: 10.1055/a-2145-4807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Chronic thromboembolic pulmonary disease (CTEPD) is an important late complication of acute pulmonary embolism, in which the thrombi transform into fibrous tissue, become integrated into the vessel wall, and lead to chronic obstructions. CTEPD is differentiated into cases without pulmonary hypertension (PH), characterized by a mean pulmonary arterial pressure up to 20 mmHg and a form with PH. Then, it is still referred to as chronic thromboembolic pulmonary hypertension (CTEPH).When there is suspicion of CTEPH, initial diagnostic tests should include echocardiography and ventilation/perfusion scan to detect perfusion defects. Subsequently, referral to a CTEPH center is recommended, where further imaging diagnostics and right heart catheterization are performed to determine the appropriate treatment.Currently, three treatment modalities are available. The treatment of choice is pulmonary endarterectomy (PEA). For non-operable patients or patients with residual PH after PEA, PH-targeted medical therapy, and the interventional procedure of balloon pulmonary angioplasty (BPA) are available. Increasingly, PEA, BPA, and pharmacological therapy are combined in multimodal concepts.Patients require post-treatment follow-up, preferably at (CTE)PH centers. These centers are required to perform a minimum number of PEA surgeries (50/year) and BPA interventions (100/year).
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Affiliation(s)
- Stefan Guth
- Abteilung für Thoraxchirurgie, Kerckhoff-Klinik GmbH, Bad Nauheim, Deutschland
| | - Heinrike Wilkens
- Klinik für Innere Medizin 5, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Michael Halank
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Deutschland
| | - Matthias Held
- Medizinische Klinik mit Schwerpunkt Pneumologie & Beatmungsmedizin, Missionsärztliche Klinik Würzburg, Würzburg, Deutschland
| | - Lukas Hobohm
- Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Stavros Konstantinides
- Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Albert Omlor
- Klinik für Innere Medizin 5, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Hans-Jürgen Seyfarth
- Bereich Pneumologie, Klinik für Onkologie, Gastroenterologie, Hepatologie und Pneumologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Hans-Joachim Schäfers
- Klinik für Thorax-Herz-Gefäßchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Eckhard Mayer
- Abteilung für Thoraxchirurgie, Kerckhoff-Klinik GmbH, Bad Nauheim, Deutschland
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Hiraoka E, Tanabe K, Izuta S, Kubota T, Kohsaka S, Kozuki A, Satomi K, Shiomi H, Shinke T, Nagai T, Manabe S, Mochizuki Y, Inohara T, Ota M, Kawaji T, Kondo Y, Shimada Y, Sotomi Y, Takaya T, Tada A, Taniguchi T, Nagao K, Nakazono K, Nakano Y, Nakayama K, Matsuo Y, Miyamoto T, Yazaki Y, Yahagi K, Yoshida T, Wakabayashi K, Ishii H, Ono M, Kishida A, Kimura T, Sakai T, Morino Y. JCS 2022 Guideline on Perioperative Cardiovascular Assessment and Management for Non-Cardiac Surgery. Circ J 2023; 87:1253-1337. [PMID: 37558469 DOI: 10.1253/circj.cj-22-0609] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | | | - Tadao Kubota
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Amane Kozuki
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | | | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, International University of Health and Welfare Narita Hospital
| | - Yasuhide Mochizuki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Taku Inohara
- Department of Cardiovascular Medicine, Keio University Graduate School of Medicine
| | - Mitsuhiko Ota
- Department of Cardiovascular Center, Toranomon Hospital
| | | | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital
| | - Yumiko Shimada
- JADECOM Academy NP·NDC Training Center, Japan Association for Development of Community Medicine
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tomofumi Takaya
- Department of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Kazuya Nagao
- Department of Cardiology, Osaka Red Cross Hospital
| | - Kenichi Nakazono
- Department of Pharmacy, St. Marianna University Yokohama Seibu Hospital
| | | | | | - Yuichiro Matsuo
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | | | | | | | | | | | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
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6
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Parvizi R, Bilehjani E, Mahmoudian B, Koohi A, Shojaan H, Ansarin K, Rashidi F. Single-Center Experience of Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension: The Results from the Tabriz University Medical Sciences (TUMS) CTEPH Program. Thorac Cardiovasc Surg 2023; 71:407-412. [PMID: 36657456 DOI: 10.1055/s-0042-1760204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Pulmonary endarterectomy (PEA) remains the preferred and potentially curative option for patients with chronic thromboembolic pulmonary hypertension (CTEPH). This study aimed to report the results of PEA for CTEPH in a tertiary center in Tabriz, Iran. METHODS We analyzed the results of 42 CTEPH patients undergoing PEA, who were enrolled in the Tabriz University of Medical Sciences (TUMS-CTEPH) from January 2016 to October 2020. The main outcome measures included the New York Heart Association (NYHA) functional classification, the 6-Minute Walk Distance, hemodynamic measures in right heart catheterization, morbidity, and mortality. RESULTS There was a significant improvement in the NYHA function class (2.6 ± 0.5 vs 1.1 ± 0.34), mean pulmonary arterial pressure (47.1 ± 13 vs 27.9 ± 8 mm Hg), cardiac output (4.3 ± 1.06 vs 5.9 ± 1.2 L/min), and pulmonary vascular resistance (709.4 ± 297.5 vs 214 ± 77 dyn s/cm5). Fifteen patients (35%) developed complications. The most common complication (10 [23%]) was reperfusion injury. Also, postsurgical mortality was 4% during hospital admission and 1-year follow-up. CONCLUSION This is the first single-center report of PEA from Iran. Post-PEA and 1-year survival were acceptable as a referral center. PEA can be performed safe with low mortality. Greater awareness of PEA and patients' access to experienced CTEPH centers are important issues.
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Affiliation(s)
- Rezayat Parvizi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Eisa Bilehjani
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Babak Mahmoudian
- Medical Radiation Sciences Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Koohi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hooriah Shojaan
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Khalil Ansarin
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farid Rashidi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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7
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Pathophysiology and Treatment of Chronic Thromboembolic Pulmonary Hypertension. Int J Mol Sci 2023; 24:ijms24043979. [PMID: 36835383 PMCID: PMC9968103 DOI: 10.3390/ijms24043979] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a condition in which an organic thrombus remains in the pulmonary artery (PA) even after receiving anticoagulation therapy for more than 3 months and is complicated by pulmonary hypertension (PH), leading to right-sided heart failure and death. CTEPH is a progressive pulmonary vascular disease with a poor prognosis if left untreated. The standard treatment for CTEPH is pulmonary endarterectomy (PEA), which is usually performed only in specialized centers. In recent years, balloon pulmonary angioplasty (BPA) and drug therapy for CTEPH have also shown good results. This review discusses the complex pathogenesis of CTEPH and presents the standard of care, PEA, as well as a new device called BPA, which is showing remarkable progress in efficacy and safety. Additionally, several drugs are now demonstrating established evidence of efficacy in treating CTEPH.
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8
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 469] [Impact Index Per Article: 469.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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9
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 1105] [Impact Index Per Article: 552.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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10
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Chronic Thromboembolic Pulmonary Hypertension: An Update. Diagnostics (Basel) 2022; 12:diagnostics12020235. [PMID: 35204326 PMCID: PMC8871284 DOI: 10.3390/diagnostics12020235] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/16/2022] [Accepted: 01/17/2022] [Indexed: 12/31/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease observed in a small proportion of patients after acute pulmonary embolism (PE). CTEPH has a high morbidity and mortality rate, related to the PH severity, and a poor prognosis, which mirrors the right ventricular dysfunction involvement. Pulmonary endarterectomy (PEA) reduces pulmonary vascular resistance, making it the treatment of choice and should be offered to operable CTEPH patients, as significant symptomatic and prognostic improvement has been observed. Moreover, these patients may also benefit from the advances made in surgical techniques and pulmonary hypertension-specific medication. However, not all patients are eligible for PEA surgery, as some have either distal pulmonary vascular obstruction and/or significant comorbidities. Therefore, surgical candidates should be carefully selected by an interprofessional team in expert centers. This review aims at making an overview of the risk factors and latest developments in diagnostic tools and treatment options for CTEPH.
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11
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Martin KA. Chronic thromboembolic pulmonary hypertension: anticoagulation and beyond. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:478-484. [PMID: 34889396 PMCID: PMC8791133 DOI: 10.1182/hematology.2021000282] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication in pulmonary embolism (PE) survivors, characterized by chronic vascular occlusion and pulmonary hypertension. The identification and diagnosis of CTEPH requires a stepwise approach, starting with symptom evaluation, functional evaluation, screening imaging, and progressing to interventional hemodynamic assessment. On the backbone of anticoagulation, CTEPH management necessitates a multidisciplinary approach. Surgical pulmonary thromboendarterectomy (PTE) is the only potentially curative option. In nonoperable disease or residual disease after PTE, interventional balloon pulmonary angioplasty and/or pulmonary-vasodilator therapies can be offered, in collaboration with interventional and vascular pulmonary colleagues. As it is a disease that can cause high morbidity and mortality, CTEPH requires a high index of suspicion to diagnose and treat in patients following PE.
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Affiliation(s)
- Karlyn A. Martin
- Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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12
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Plácido R, Guimarães T, Jenkins D, Cortez-Dias N, Pereira SC, Campos P, Mineiro A, Lousada N, Martins SR, Moreira S, Dias AR, Resende CL, Vieira R, Pinto FJ. Chronic thromboembolic pulmonary hypertension: Initial experience of patients undergoing pulmonary thromboendarterectomy. Rev Port Cardiol 2021; 40:741-752. [PMID: 34857112 DOI: 10.1016/j.repce.2021.08.002] [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: 08/14/2020] [Accepted: 10/13/2020] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Pulmonary endarterectomy (PEA) is a potentially curative procedure in patients with chronic thromboembolic pulmonary hypertension (CTEPH). This study reports the initial experience of a Portuguese PH center with patients undergoing PEA at an international surgical reference center. METHODS Prospective observational study of consecutive CTEPH patients followed at a national PH center, who underwent PEA at an international surgical reference center between October 2015 and March 2019. Clinical, functional, laboratory, imaging and hemodynamic parameters were obtained in the 12 months preceding the surgery and repeated between four and six months after PEA. RESULTS 27 consecutive patients (59% female) with a median age of 60 (49-71) years underwent PEA. During a median follow-up of 34 (21-48) months, there was an improvement in functional class in all patients, with only one cardiac death. From a hemodynamic perspective, there was a reduction in mean pulmonary artery pressure from 48 (42-59) mmHg to 26 (22-38) mmHg, an increase in cardiac output from 3.3 (2.9-4.0) L/min to 4.9 (4.2-5.5) L/min and a reduction in pulmonary vascular resistance from 12.1 (7.2-15.5) uW to 3.5 (2.6-5,2) uW. During the follow-up, 44% (n=12) of patients had no PH criteria, 44% (n=12) had residual PH and 11% (n=3) had PH recurrence. There was a reduction of N-terminal pro-B-type natriureticpeptide from 868 (212-1730) pg/mL to 171 (98-382) pg/mL. Rright ventricular systolic function parameters revealed an improvement in longitudinal systolic excursion and peak velocity of the plane of the tricuspid ring from 14 (13-14) mm and 9 (8-10) cm/s to 17 (16-18) mm and 13 (11-15) cm/s, respectively. Of the 26 patients with preoperative right ventricular dysfunction, 85% (n=22) recovered. The proportion of patients on specific vasodilator therapy decreased from 93% to 44% (p<0.001) and the proportion of those requiring oxygen therapy decreased from 52% to 26% (p=0.003). The six-minute walk test distance increased by about 25% compared to the baseline and only eight patients had significant desaturation during the test. CONCLUSION Pulmonary endarterectomy performed at an experienced high-volume center is a safe procedure with a very favorable medium-term impact on functional, hemodynamic and right ventricular function parameters in CTEPH patients with operable disease. It is possible for PH centers without PEA differentiation to refer patients safely and effectively to an international surgical center in which air transport is necessary.
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Affiliation(s)
- Rui Plácido
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal; Faculty of Medicine, University of Lisbon, Lisboa, Portugal.
| | - Tatiana Guimarães
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal; Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - David Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Inglaterra, United Kingdom
| | - Nuno Cortez-Dias
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal; Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - Sara Couto Pereira
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal
| | - Paula Campos
- Radiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Lisboa, Portugal
| | - Ana Mineiro
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Nuno Lousada
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal
| | - Susana R Martins
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal; Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - Susana Moreira
- Faculty of Medicine, University of Lisbon, Lisboa, Portugal; Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Ana Rocha Dias
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | | | - Rita Vieira
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal
| | - Fausto J Pinto
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal
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13
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Comparative Efficacy and Safety of Targeted Therapies for Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review and Network Meta-Analysis. Can Respir J 2021; 2021:1626971. [PMID: 34512819 PMCID: PMC8426079 DOI: 10.1155/2021/1626971] [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] [Received: 04/22/2021] [Revised: 08/03/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022] Open
Abstract
Background There is significant controversy relating to whether chronic thromboembolic pulmonary hypertension (CTEPH) can be treated with pulmonary arterial hypertension- (PAH-) targeted therapies and which therapy is the optimal choice for patients. A large number of randomized controlled trials (RCTs) have compared PAH-targeted therapies with placebo or conventional therapies. In this study, we aimed to compare all of the PAH-targeted medications that are used to treat CTEPH and rank their efficacy by the application of network meta-analysis (NMA). Methods We searched PubMed, EMBASE, Web of Science, the Cochrane Central Register, https://clinicaltrials.gov, and who.int/trialsearch/, for relevant RCTs published up to January 2020. In addition to traditional meta-analysis, we also performed NMA in our systematic review, as deployed in a previous protocol (PROSPERO: CRD42020173765). Results Our study identified eight eligible RCTs that evaluated seven PAH-targeted therapies in 703 patients with CTEPH. NMA revealed that riociguat was ranked first as the most optimized therapy for ameliorating the 6-minute walk distance with a probability of 80.4%. Bosentan was significantly better than others with regard to reducing brain natriuretic peptide/N-terminal pro-B-type natriuretic peptide with a probability of 84.3%. Sildenafil was identified as the best drug in terms of improving the New York Heart Association/World Health Organization functional class with a probability of 87.3%. Treprostinil and macitentan were more beneficial than other drugs in reducing pulmonary vascular resistance and lowering the incidence of clinical worsening with probabilities of 86.2% and 79.2%, respectively. Conclusion Analysis revealed positive advantages for the use of PAH-targeted drugs in patients with CTEPH. Overall, treprostinil and riociguat were superior to all other PAH-targeted medications in most of the outcomes investigated.
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14
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Plácido R, Guimarães T, Jenkins D, Cortez-Dias N, Pereira SC, Campos P, Mineiro A, Lousada N, Martins SR, Moreira S, Dias AR, Resende CL, Vieira R, Pinto FJ. Chronic thromboembolic pulmonary hypertension: initial experience of patients undergoing pulmonary thromboendarterectomy. Rev Port Cardiol 2021; 40:S0870-2551(21)00248-1. [PMID: 34474956 DOI: 10.1016/j.repc.2020.10.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Pulmonary endarterectomy (PEA) is a potentially curative procedure in patients with chronic thromboembolic pulmonary hypertension (CTEPH). This study reports the initial experience of a Portuguese PH center with patients undergoing PEA at an international surgical reference center. METHODS Prospective observational study of consecutive CTEPH patients followed at a national PH center, who underwent PEA at an international surgical reference center between October 2015 and March 2019. Clinical, functional, laboratory, imaging and hemodynamic parameters were obtained in the 12 months preceding the surgery and repeated between four and six months after PEA. RESULTS 27 consecutive patients (59% female) with a median age of 60 (49-71) years underwent PEA. During a median follow-up of 34 (21-48) months, there was an improvement in functional class in all patients, with only one cardiac death. From a hemodynamic perspective, there was a reduction in mean pulmonary artery pressure from 48 (42-59) mmHg to 26 (22-38) mmHg, an increase in cardiac output from 3.3 (2.9-4.0) L/min to 4.9 (4.2-5.5) L/min and a reduction in pulmonary vascular resistance from 12.1 (7.2-15.5) uW to 3.5 (2.6-5, 2) uW. During the follow-up, 44% (n=12) of patients had no PH criteria, 44% (n=12) had residual PH and 11% (n = 3) had PH recurrence. There was a reduction of N-terminal pro-B-type natriureticpeptide from 868 (212-1730) pg/mL to 171 (98-382) pg/mL. Rright ventricular systolic function parameters revealed an improvement in longitudinal systolic excursion and peak velocity of the plane of the tricuspid ring from 14 (13-14) mm and 9 (8-10) cm/s to 17 (16-18) mm and 13 (11-15) cm/s, respectively. Of the 26 patients with preoperative right ventricular dysfunction, 85% (n=22) recovered. The proportion of patients on specific vasodilator therapy decreased from 93% to 44% (p<0.001) and the proportion of those requiring oxygen therapy decreased from 52% to 26% (p=0.003). The six-minute walk test distance increased by about 25% compared to the baseline and only eight patients had significant desaturation during the test. CONCLUSION Pulmonary endarterectomy performed at an experienced high-volume center is a safe procedure with a very favorable medium-term impact on functional, hemodynamic and right ventricular function parameters in CTEPH patients with operable disease. It is possible for PH centers without PEA differentiation to refer patients safely and effectively to an international surgical center in which air transport is necessary.
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Affiliation(s)
- Rui Plácido
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal; Faculty of Medicine, University of Lisbon, Lisboa, Portugal.
| | - Tatiana Guimarães
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal; Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - David Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Inglaterra
| | - Nuno Cortez-Dias
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal; Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - Sara Couto Pereira
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal
| | - Paula Campos
- Radiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Lisboa, Portugal
| | - Ana Mineiro
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Nuno Lousada
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal
| | - Susana R Martins
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal; Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - Susana Moreira
- Faculty of Medicine, University of Lisbon, Lisboa, Portugal; Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Ana Rocha Dias
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | | | - Rita Vieira
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal
| | - Fausto J Pinto
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal
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15
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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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16
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Delcroix M, Torbicki A, Gopalan D, Sitbon O, Klok FA, Lang I, Jenkins D, Kim NH, Humbert M, Jais X, Vonk Noordegraaf A, Pepke-Zaba J, Brénot P, Dorfmuller P, Fadel E, Ghofrani HA, Hoeper MM, Jansa P, Madani M, Matsubara H, Ogo T, Grünig E, D'Armini A, Galie N, Meyer B, Corkery P, Meszaros G, Mayer E, Simonneau G. ERS statement on chronic thromboembolic pulmonary hypertension. Eur Respir J 2021; 57:13993003.02828-2020. [PMID: 33334946 DOI: 10.1183/13993003.02828-2020] [Citation(s) in RCA: 259] [Impact Index Per Article: 86.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/05/2020] [Indexed: 12/25/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism, either symptomatic or not. The occlusion of proximal pulmonary arteries by fibrotic intravascular material, in combination with a secondary microvasculopathy of vessels <500 µm, leads to increased pulmonary vascular resistance and progressive right heart failure. The mechanism responsible for the transformation of red clots into fibrotic material remnants has not yet been elucidated. In patients with pulmonary hypertension, the diagnosis is suspected when a ventilation/perfusion lung scan shows mismatched perfusion defects, and confirmed by right heart catheterisation and vascular imaging. Today, in addition to lifelong anticoagulation, treatment modalities include surgery, angioplasty and medical treatment according to the localisation and characteristics of the lesions.This statement outlines a review of the literature and current practice concerning diagnosis and management of CTEPH. It covers the definitions, diagnosis, epidemiology, follow-up after acute pulmonary embolism, pathophysiology, treatment by pulmonary endarterectomy, balloon pulmonary angioplasty, drugs and their combination, rehabilitation and new lines of research in CTEPH.It represents the first collaboration of the European Respiratory Society, the International CTEPH Association and the European Reference Network-Lung in the pulmonary hypertension domain. The statement summarises current knowledge, but does not make formal recommendations for clinical practice.
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Affiliation(s)
- Marion Delcroix
- Clinical Dept of Respiratory Diseases, Pulmonary Hypertension Center, UZ Leuven, Leuven, Belgium .,BREATHE, Dept CHROMETA, KU Leuven, Leuven, Belgium.,Co-chair
| | - Adam Torbicki
- Dept of Pulmonary Circulation, Thrombo-embolic Diseases and Cardiology, Center of Postgraduate Medical Education, ECZ-Otwock, Otwock, Poland.,Section editors
| | - Deepa Gopalan
- Dept of Radiology, Imperial College Hospitals NHS Trusts, London, UK.,Section editors
| | - Olivier Sitbon
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Frederikus A Klok
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Section editors
| | - Irene Lang
- Medical University of Vienna, Vienna, Austria.,Section editors
| | - David Jenkins
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK.,Section editors
| | - Nick H Kim
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA, USA.,Section editors
| | - Marc Humbert
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Xavier Jais
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Section editors
| | - Joanna Pepke-Zaba
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK.,Section editors
| | - Philippe Brénot
- Marie Lannelongue Hospital, Paris-South University, Le Plessis Robinson, France
| | - Peter Dorfmuller
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,Dept of Pneumology, Kerckhoff-Clinic Bad Nauheim, Bad Nauheim, Germany
| | - Elie Fadel
- Hannover Medical School, Hannover, Germany
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,Dept of Pneumology, Kerckhoff-Clinic Bad Nauheim, Bad Nauheim, Germany
| | | | - Pavel Jansa
- 2nd Department of Medicine, Dept of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Michael Madani
- Sulpizio Cardiovascular Centre, University of California, San Diego, CA, USA
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Takeshi Ogo
- National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Ekkehard Grünig
- Thoraxklinik Heidelberg at Heidelberg University Hospital, Heidelberg, Germany
| | - Andrea D'Armini
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | | | - Bernhard Meyer
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | | | | | - Eckhard Mayer
- Dept of Thoracic Surgery, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany.,Equal contribution.,Co-chair
| | - Gérald Simonneau
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Equal contribution.,Co-chair
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Madani MM. Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: state-of-the-art 2020. Pulm Circ 2021; 11:20458940211007372. [PMID: 34104418 PMCID: PMC8150486 DOI: 10.1177/20458940211007372] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/26/2021] [Indexed: 11/18/2022] Open
Abstract
Pulmonary endarterectomy is the treatment of choice for patients with operable chronic thromboembolic pulmonary hypertension (CTEPH) as it is potentially curative. In expert centers that conduct > 50 pulmonary endarterectomy procedures per year, peri- and post-surgical mortality rates are very low and long-term outcomes are excellent, with three-year post-operative survival of > 80%. Therapeutic decisions in CTEPH are based largely on the location of the arterial obstruction, with pulmonary endarterectomy for obstructions in main, lobar, and segmental vessels, and balloon pulmonary angioplasty and medical therapy for small-vessel disease. Medical therapy is also an option for patients with persistent/recurrent pulmonary hypertension after pulmonary endarterectomy or balloon pulmonary angioplasty. With increasing surgical experience and improvements in instruments and procedures, an increasing number of patients are now considered operable who would previously have been inoperable, including some patients with subsegmental disease. At our University (University of California San Diego), around 200 pulmonary endarterectomy procedures are performed every year and several advances have been developed, including resection of more distal disease, availability of pulmonary endarterectomy to patients previously considered to be at too high risk for surgery, improved management of post-pulmonary endarterectomy complications, and minimally invasive pulmonary endarterectomy. Pulmonary endarterectomy can be combined with other treatment modalities, including balloon pulmonary angioplasty, medical therapy for persistent/recurrent pulmonary hypertension after pulmonary endarterectomy, and medical therapy or balloon pulmonary angioplasty as bridging therapy before surgery. Data on these combinations are, however, limited. Combination treatment should therefore be considered on an individual patient basis. In the future, however, multimodal therapy with pulmonary endarterectomy, balloon pulmonary angioplasty, and/or medical therapy is likely to be an important treatment option for many patients.
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Affiliation(s)
- Michael M. Madani
- Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, CA, USA
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18
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Abstract
BACKGROUND Pulmonary arterial hypertension is a devastating disease that leads to right heart failure and premature death. Endothelin receptor antagonists have shown efficacy in the treatment of pulmonary arterial hypertension. OBJECTIVES To evaluate the efficacy of endothelin receptor antagonists (ERAs) in pulmonary arterial hypertension. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and the reference sections of retrieved articles. The searches are current as of 4 November 2020. SELECTION CRITERIA We included randomised trials and quasi-randomised trials involving participants with pulmonary arterial hypertension. DATA COLLECTION AND ANALYSIS Two of five review authors selected studies, extracted data and assessed study quality according to established criteria. We used standard methods expected by Cochrane. The primary outcomes were exercise capacity (six-minute walk distance, 6MWD), World Health Organization (WHO) or New York Heart Association (NYHA) functional class, Borg dyspnoea scores and dyspnoea-fatigue ratings, and mortality. MAIN RESULTS We included 17 randomised controlled trials involving a total of 3322 participants. Most trials were of relatively short duration (12 weeks to six months). Sixteen trials were placebo-controlled, and of these nine investigated a non-selective ERA and seven a selective ERA. We evaluated two comparisons in the review: ERA versus placebo and ERA versus phosphodiesterase type 5 (PDE5) inhibitor. The abstract focuses on the placebo-controlled trials only and presents the pooled results of selective and non-selective ERAs. After treatment, participants receiving ERAs could probably walk on average 25.06 m (95% confidence interval (CI) 17.13 to 32.99 m; 2739 participants; 14 studies; I2 = 34%, moderate-certainty evidence) further than those receiving placebo in a 6MWD. Endothelin receptor antagonists probably improved more participants' WHO functional class (odds ratio (OR) 1.41, 95% CI 1.16 to 1.70; participants = 3060; studies = 15; I2 = 5%, moderate-certainty evidence) and probably lowered the odds of functional class deterioration (OR 0.43, 95% CI 0.26 to 0.72; participants = 2347; studies = 13; I2 = 40%, moderate-certainty evidence) compared with placebo. There may be a reduction in mortality with ERAs (OR 0.78, 95% CI 0.58, 1.07; 2889 participants; 12 studies; I2 = 0%, low-certainty evidence), and pooled data suggest that ERAs probably improve cardiopulmonary haemodynamics and may reduce Borg dyspnoea score in symptomatic patients. Hepatic toxicity was not common, but may be increased by ERA treatment from 37 to 67 (95% CI 34 to 130) per 1000 over 25 weeks of treatment (OR 1.88, 95% CI 0.91 to 3.90; moderate-certainty evidence). Although ERAs were well tolerated in this population, several cases of irreversible liver failure caused by sitaxsentan have been reported, which led the licence holder for sitaxsentan to withdraw the product from all markets worldwide. As planned, we performed subgroup analyses comparing selective and non-selective ERAs, and with the exception of mean pulmonary artery pressure, did not detect any clear subgroup differences for any outcome. AUTHORS' CONCLUSIONS For people with pulmonary arterial hypertension with WHO functional class II and III, endothelin receptor antagonists probably increase exercise capacity, improve WHO functional class, prevent WHO functional class deterioration, result in favourable changes in cardiopulmonary haemodynamic variables compared with placebo. However, they are less effective in reducing dyspnoea and mortality. The efficacy data were strongest in those with idiopathic pulmonary hypertension. The irreversible liver failure caused by sitaxsentan and its withdrawal from global markets emphasise the importance of hepatic monitoring in people treated with ERAs. The question of the effects of ERAs on pulmonary arterial hypertension has now likely been answered.. The combined use of ERAs and phosphodiesterase inhibitors may provide more benefit in pulmonary arterial hypertension; however, this needs to be confirmed in future studies.
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Affiliation(s)
- Chao Liu
- Division of Cardiology, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Junmin Chen
- Department of Haematology and Rheumatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yanqiu Gao
- The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Bao Deng
- The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Kunshen Liu
- The First Hospital of Hebei Medical University, Shijiazhuang, China
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Kunihara T, Wilkens H, Halank M, Held M, Nomura R, Igarashi T, Sata F, Schäfers HJ. Haemodynamic benefit of bridging use of bosentan prior to pulmonary endarterectomy. Eur J Cardiothorac Surg 2021; 60:840-847. [PMID: 33755096 DOI: 10.1093/ejcts/ezab137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 02/09/2021] [Accepted: 02/14/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Some patients present with excessive pulmonary hypertension (PH) prior to pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH). This study was performed to evaluate the clinical role of pretreatment before PEA in CTEPH patients. METHODS A total of 370 patients with CTEPH undergoing first PEA between 2003 and 2017 were divided into those receiving pretreatment with bosentan (group B: n = 119) and those without targeted pretreatment for PH (group C: n = 251). After selecting patients given bosentan (2-8 months) and using propensity score matching, comparable patient cohorts (n = 23 each) were created from both groups. PEA was performed in the standard manner, and the median number of extracted segments was 14. RESULTS There were no significant differences in perioperative demographic characteristics or 30-day mortality (overall 5.7%) between the groups before and after matching. In patients with preoperative pulmonary vascular resistance (PVR) ≥800 dynes s/cm5, a significantly larger decrease in PVR was found in group B (78%) compared to group C (68%) (P = 0.033). There was no significant difference in late survival between the groups after matching. The frequency of residual/persistent PH (mean pulmonary artery pressure >25 mmHg) was lower in group B than in group C, although the difference was not significant (22% vs 39%, respectively, P = 0.200). Advanced age and longer cardiopulmonary bypass time were independent predictors of both 30-day mortality and residual/persistent PH (odds ratio: age, 1.053, 1.013, cardiopulmonary bypass time, 1.065, 1.010, respectively). CONCLUSIONS Preoperative treatment of CTEPH patients with bosentan for 2-8 months can improve post-PEA PVR without adverse clinical events in patients with a high preoperative PVR. A temporary bridging regime appears beneficial in selected patients prior to PEA.
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Affiliation(s)
- Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Heinrike Wilkens
- Department of Pulmonary Medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Michael Halank
- Department of Internal Medicine I, Pneumology, University Hospital Dresden, Dresden, Germany
| | - Matthias Held
- Department of Internal Medicine and Respiratory Care, Mission Medical Hospital, Würzburg, Germany
| | - Ryota Nomura
- Department of Cardiovascular Surgery, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Takashi Igarashi
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | | | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
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20
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Ghofrani HA, D'Armini AM, Kim NH, Mayer E, Simonneau G. Interventional and pharmacological management of chronic thromboembolic pulmonary hypertension. Respir Med 2021; 177:106293. [PMID: 33465538 DOI: 10.1016/j.rmed.2020.106293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 12/11/2020] [Accepted: 12/27/2020] [Indexed: 11/24/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by obstruction of the pulmonary vasculature, leading to increased pulmonary vascular resistance and ultimately right ventricular failure, the leading cause of death in non-operated patients. This article reviews the current management of CTEPH. The standard of care in CTEPH is pulmonary endarterectomy (PEA). However, up to 40% of patients with CTEPH are ineligible for PEA, and up to 51% develop persistent/recurrent PH after PEA. Riociguat is currently the only medical therapy licensed for treatment of inoperable or persistent/recurrent CTEPH after PEA based on the results of the Phase III CHEST-1 study. Studies of balloon pulmonary angioplasty (BPA) have shown benefits in patients with inoperable or persistent/recurrent CTEPH after PEA; however, data are lacking from large, prospective, controlled studies. Studies of macitentan in patients with inoperable CTEPH and treprostinil in patients with inoperable or persistent/recurrent CTEPH showed positive results. Combination therapy is under evaluation in CTEPH, and long-term data are not available. In the future, CTEPH may be managed by PEA, medical therapy or BPA - alone or in combination, according to individual patient needs. Patients should be referred to experienced centers capable of assessing and delivering all options.
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Affiliation(s)
- Hossein-Ardeschir Ghofrani
- Department of Internal Medicine, University of Giessen and Marburg Lung Center, Giessen, Germany; Department of Pneumology, Kerckhoff-Klinik, Bad Nauheim, Germany; Department of Medicine, Imperial College London, London, UK.
| | - Andrea M D'Armini
- Department of Cardio-Thoracic and Vascular Surgery, Heart and Lung Transplantation and Pulmonary Hypertension Unit, Foundation IRCCS Policlinico San Matteo, University of Pavia School of Medicine, Pavia, Italy
| | - Nick H Kim
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, USA
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany; Member of the German Center for Lung Research (DZL), Germany
| | - Gérald Simonneau
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique, Le Kremlin, Bicêtre, France
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21
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Arami S, Taghavi S, Sadeghipour P, Amini S, Naderi N, Amin A, Pouraliakbar H, Alizadehasl A, Shafe O, Moosav J, Ghavidel A, Mohebbi B, Totonchi Z, Azarfarin R, Sadeghi H, Mirdamadi M, Malek H, Rezaei-Kalantari K. The preliminary diagnostic and therapeutic outcomes of chronic thromboembolic pulmonary hypertension registry rajaie cardiovascular medical and research center. Res Cardiovasc Med 2021. [DOI: 10.4103/rcm.rcm_6_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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22
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by unresolved thrombi in the pulmonary arteries and microvasculopathy in nonoccluded areas. If left untreated, progressive pulmonary hypertension will induce right heart failure and, finally, death. Currently, pulmonary endarterectomy (PEA) remains the only method that has the potential to cure CTEPH. Unfortunately, up to 40% of patients are ineligible for this procedure for various reasons. In recent years, refined balloon pulmonary angioplasty (BPA) has become an alternative option for inoperable CTEPH patients, and it may be another curative treatment in the future, particularly in combination with prior PEA. Nevertheless, 23% of patients still suffer from persistent PH after BPA. Given that CTEPH shares many similarities with idiopathic pulmonary arterial hypertension (PAH), targeted drugs developed for PAH are also attractive options for CTEPH, especially for inoperable or persistent/recurrent CTEPH patients. To date, riociguat, macitentan, and subcutaneous treprostinil are the only drugs proven by randomized control trials to be capable of improving the exercise capacity (6-min walking distance) of CTEPH patients. In this review, we summarize the achievements and unresolved problems of PAH-targeted therapy for CTEPH over the last decade.
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23
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Ranka S, Mohananey D, Agarwal N, Verma BR, Villablanca P, Mewhort HE, Ramakrishna H. Chronic Thromboembolic Pulmonary Hypertension-Management Strategies and Outcomes. J Cardiothorac Vasc Anesth 2019; 34:2513-2523. [PMID: 31883688 DOI: 10.1053/j.jvca.2019.11.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/14/2019] [Indexed: 11/11/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is rare but complex pathophysiological disease with hallmark features of chronic thrombotic mechanical obstruction, right ventricular dysfunction, and secondary pulmonary arteriopathy. It increasingly is being understood that chronic infection/inflammation, abnormal fibrinolysis, and cytokines play an important role in pathogenesis such that only a subset of patients with pulmonary embolism develop CTEPH. Diagnosis remains challenging given the lack of early clinical signs and overlap with other cardiopulmonary conditions. Pulmonary endarterectomy is the surgical procedure of choice with good postoperative survival and functional outcomes, especially when done at high-volume centers with a multidisciplinary approach. There has been a resurgence of balloon pulmonary angioplasty (BPA) as salvage therapy for inoperable CTEPH or in its newfound hybrid role for persistent postoperative pulmonary hypertension with excellent 1-year and 3-year survival. Use of riociguat has shown promising improvements in functional outcomes up to 2 years after initiation. Endothelin receptor antagonists serve a supplemental role postoperatively or in inoperable CTEPH. The role of drug therapy preoperatively or in tandem with BPA is currently under investigation.
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Affiliation(s)
- Sagar Ranka
- Department of Cardiovascular Medicine, Kansas University Medical Center, Kansas City, KS
| | - Divyanshu Mohananey
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Nikhil Agarwal
- Division of Cardiovascular Medicine, University of Buffalo, Buffalo, NY
| | - Beni Rai Verma
- Department of Cardiology, Cleveland Clinic, Cleveland, OH
| | | | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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24
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van Thor MCJ, Ten Klooster L, Snijder RJ, Kelder JC, Mager JJ, Post MC. Bosentan or Macitentan Therapy in Chronic Thromboembolic Pulmonary Hypertension? Lung 2019; 197:753-760. [PMID: 31583452 DOI: 10.1007/s00408-019-00274-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/19/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Research comparing bosentan and macitentan in chronic thromboembolic pulmonary hypertension (CTEPH) is scarce, although macitentan might have superior pharmacologic properties. We present the first real-world, 2-year follow-up results and compare clinical outcomes of both drugs in CTEPH. METHODS All consecutive, technical inoperable or residual CTEPH patients receiving bosentan or macitentan, diagnosed in our multidisciplinary team between January 2003 and January 2019, were included. We report and compare survival, clinical worsening (CW), adverse events, WHO FC, NT-proBNP and 6-min walking test (6MWT) until 2 years after medication initiation. RESULTS In total, 112 patients receiving bosentan or macitentan (58% female, mean age 62 ± 14 years, 68% WHO FC III/IV, 51% bosentan) could be included. Mean treatment duration was 1.9 ± 0.4 years for bosentan and 1.2 ± 0.6 years for macitentan. Two-year survival rate was 91% for bosentan and 80% for macitentan (HR mortality macitentan 1.85 [0.56-6.10], p = 0.31). Two-year CW-free survival was 81% and 58%, respectively (HR CW macitentan 2.16 [0.962-4.87], p = 0.06). Right atrial pressure, cardiac output (for mortality alone) and 6MWT lowest saturation were multivariate predictors at baseline. Overall adverse event rates were comparable and WHO FC, NT-proBNP and 6MWT distance improved similar for both drugs till 2-year follow-up. CONCLUSION CTEPH patients receiving bosentan or macitentan have improved clinical outcomes till 2-year follow-up, without significant differences in outcomes between both therapies.
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Affiliation(s)
- M C J van Thor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - L Ten Klooster
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - R J Snijder
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J C Kelder
- Department of Epidemiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J J Mager
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M C Post
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
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25
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Zhang J, Li J, Huang Z, Xu J, Fan Y. A meta‐analysis of randomized controlled trials in targeted treatments of chronic thromboembolic pulmonary hypertension. CLINICAL RESPIRATORY JOURNAL 2019; 13:467-479. [PMID: 31059198 DOI: 10.1111/crj.13034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 04/12/2019] [Accepted: 04/28/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Jing Zhang
- Department of Respiratory Disease Xinqiao Hospital, Third Military Medical University Chongqing China
| | - Jing‐Meng Li
- Department of Thoracic Surgery Xinqiao Hospital, Third Military Medical University Chongqing China
| | - Zan‐Sheng Huang
- Department of Respiratory Disease Xinqiao Hospital, Third Military Medical University Chongqing China
| | - Jian‐Cheng Xu
- Department of Respiratory Disease Xinqiao Hospital, Third Military Medical University Chongqing China
| | - Ye Fan
- Department of Respiratory Disease Xinqiao Hospital, Third Military Medical University Chongqing China
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26
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Wilkens H, Konstantinides S, Lang IM, Bunck AC, Gerges M, Gerhardt F, Grgic A, Grohé C, Guth S, Held M, Hinrichs JB, Hoeper MM, Klepetko W, Kramm T, Krüger U, Lankeit M, Meyer BC, Olsson KM, Schäfers HJ, Schmidt M, Seyfarth HJ, Ulrich S, Wiedenroth CB, Mayer E. Chronic thromboembolic pulmonary hypertension (CTEPH): Updated Recommendations from the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:69-78. [PMID: 30195840 DOI: 10.1016/j.ijcard.2018.08.079] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 10/28/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a subgroup of pulmonary hypertension that differs from all other forms of PH in terms of its pathophysiology, patient characteristics and treatment. For implementation of the European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension in Germany, the Cologne Consensus Conference 2016 was held and last updated in spring of 2018. One of the working groups was dedicated to CTEPH, practical and controversial issues were commented and updated. In every patient with suspected PH, CTEPH or chronic thromboembolic disease (CTED, i.e. symptomatic residual vasculopathy without pulmonary hypertension) should be excluded. Primary treatment is surgical pulmonary endarterectomy (PEA) in a multidisciplinary CTEPH centre. Inoperable patients or patients with persistent or recurrent CTEPH after PEA are candidates for targeted drug therapy. There is increasing experience with balloon pulmonary angioplasty (BPA) for inoperable patients; this option, like PEA, is reserved for specialised centres with expertise in this treatment method.
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Affiliation(s)
- Heinrike Wilkens
- Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, University Hospital of Saarland, 66421 Homburg, Saar, Germany.
| | - Stavros Konstantinides
- Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin der Johannes-Gutenberg Universität Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Irene M Lang
- Klinik für Innere Medizin II, Abt. Kardiologie, Medizinische Universität Wien, Austria
| | - Alexander C Bunck
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinik Köln, Germany
| | - Mario Gerges
- Klinik für Innere Medizin II, Abt. Kardiologie, Medizinische Universität Wien, Austria
| | - Felix Gerhardt
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinik Köln, Germany
| | | | - Christian Grohé
- Klinik für Pneumologie Evangelische Lungenklinik Berlin, Buch, 13125 Berlin, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff-Clinic GmbH, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Matthias Held
- Missionsärztliche Klinik Würzburg, Innere Medizin, Pneumologie/Kardiologie, Zentrum für pulmonale Hyertonie und Lungengefäßkrankheiten, Germany
| | - Jan B Hinrichs
- Institut für Diagnostische und Interventionelle Radiologie, Medizinische Hochschule Hannover, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; Deutsches Zentrum für Lungenforschung (DZL), Germany
| | - Walter Klepetko
- Klinische Abteilung für Thoraxchirurgie, Medizinische Universität Wien, Austria
| | - Thorsten Kramm
- Department of Thoracic Surgery, Kerckhoff-Clinic GmbH, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Ulrich Krüger
- Klinik für Kardiologie und Angiologie, Herzzentrum Duisburg, Germany
| | - Mareike Lankeit
- Medizinische Klinik mit Schwerpunkt Kardiologie, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Bernhard C Meyer
- Institut für Diagnostische und Interventionelle Radiologie, Medizinische Hochschule Hannover, Germany
| | - Karen M Olsson
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Hans-Joachim Schäfers
- Klinik für Thorax-Herz-Gefäßchirurgie, Universitätsklinikum des Saarlandes, 66421 Homburg, Germany
| | - Matthias Schmidt
- Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Köln, 50937 Köln, Germany
| | - Hans-J Seyfarth
- Abteilung Pneumologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig, Germany
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital of Zurich, Switzerland
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Kerckhoff-Clinic GmbH, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff-Clinic GmbH, Benekestr. 2-8, 61231 Bad Nauheim, Germany
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27
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Tromeur C, Jaïs X, Mercier O, Couturaud F, Montani D, Savale L, Jevnikar M, Weatherald J, Sitbon O, Parent F, Fabre D, Mussot S, Dartevelle P, Humbert M, Simonneau G, Fadel E. Factors predicting outcome after pulmonary endarterectomy. PLoS One 2018; 13:e0198198. [PMID: 29927944 PMCID: PMC6013172 DOI: 10.1371/journal.pone.0198198] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/15/2018] [Indexed: 11/18/2022] Open
Abstract
Objective Few studies have reported predictive factors of outcome after pulmonary endarterectomy (PEA) in chronic thromboembolic pulmonary hypertension. The purpose of this study was to determine factors influencing mortality and predictors of hemodynamic improvement after PEA. Methods A total of 383 consecutive patients who underwent PEA between January 2005 and December 2009 were retrospectively reviewed. Among them, 150 were fully reevaluated 7.5±1 months after PEA by NYHA class, 6–minute walk distance (6MWD), percentage of predicted carbon monoxide transfer factor (TLCO) and right heart catheterisation. Results Mortality rates at 1 month, 1 year and 3 years were 2.8%, 6.9% and 7.5%, respectively. Preoperative pulmonary vascular resistance (PVR) independently predicted 1-month, 1- and 3-year mortality and age predicted mortality at 1 year and 3 years. Significant improvement in NYHA class and 6MWD were observed and PVR decreased from 773±353 to 307±221 dyn.sec.cm-5 (p<0.001). In 96 patients (64%), PVR decreased by at least 50% and/or was reduced to lower than 250 dyn.sec.cm-5. Preoperative cardiac output (CO) and TLCO predicted hemodynamic improvement. Conclusion PEA is associated with an excellent long-term survival and a marked improvement in clinical status and hemodynamics. Some preoperative factors including PVR, CO and TLCO can predict postoperative outcomes.
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Affiliation(s)
- Cécile Tromeur
- European Brittany University, Brest, France
- Department of Internal Medicine and Chest Diseases, University Hospital Centre La Cavale Blanche, Brest, France
- Groupe d’Etude de la Thrombose de Bretagne Occidentale (GETBO), EA 3878, CIC INSERM 1412, Brest, France
- * E-mail:
| | - Xavier Jaïs
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Olaf Mercier
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Francis Couturaud
- European Brittany University, Brest, France
- Department of Internal Medicine and Chest Diseases, University Hospital Centre La Cavale Blanche, Brest, France
- Groupe d’Etude de la Thrombose de Bretagne Occidentale (GETBO), EA 3878, CIC INSERM 1412, Brest, France
| | - David Montani
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Laurent Savale
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Mitja Jevnikar
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Jason Weatherald
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
| | - Olivier Sitbon
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Florence Parent
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Dominique Fabre
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Sacha Mussot
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Philippe Dartevelle
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Marc Humbert
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Gérald Simonneau
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Elie Fadel
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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Chen X, Zhai Z, Huang K, Xie W, Wan J, Wang C. Bosentan therapy for pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension: A systemic review and meta-analysis. THE CLINICAL RESPIRATORY JOURNAL 2018; 12:2065-2074. [PMID: 29393580 DOI: 10.1111/crj.12774] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 01/03/2018] [Accepted: 01/29/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Bosentan therapy has been recommended for pulmonary arterial hypertension (PAH) and might be beneficial for chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to evaluate the specific effects of bosentan for PAH and CTEPH. MATERIALS AND METHODS We performed a systemic review and meta-analysis of randomized controlled trials (RCTs), comparing efficacy and safety of bosentan treatment for PAH and CTEPH through major biomedical database. RESULTS A total of 10 RCTs including 1185 patients were enrolled. For PAH patients, bosentan prolonged 6-minute walk distance with a weighted mean difference of 35.7 m, reduced mean pulmonary arterial pressure by 5.7 mm Hg, increased cardiac index by 0.4 L/min/m2 , reduced pulmonary vascular resistance by 305.1 dyn·s/cm5 , prevented functional class from deterioration and reduced clinical worsening as compared with placebo. For CTEPH patients, bosentan improved cardiac index by 0.3 L/min/m2 and reduced pulmonary vascular resistance by 176.0 dyn·s/cm5 . Other efficacy outcomes regarding CTEPH did not attain statistical difference. For both PAH and CTEPH, there was no significant difference in mortality or adverse event between bosentan and placebo group. However, bosentan raised the risk of abnormal liver function in both PAH and CTEPH patients. CONCLUSIONS Bosentan is effective in treating PAH, whereas it improves only certain hemodynamic parameters of CTEPH. Incidence of liver function abnormality is higher in bosentan treatment.
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Affiliation(s)
- Xinwang Chen
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
- The Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
- Department of Medicine, Peking University Health Science Center, Beijing, China
| | - Zhenguo Zhai
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
- The Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Ke Huang
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
- The Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Wanmu Xie
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
- The Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Jun Wan
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
- The Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Chen Wang
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
- The Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
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Torbicki A. Macitentan for treatment of CTEPH: why MERIT merits attention. THE LANCET RESPIRATORY MEDICINE 2017; 5:762-763. [DOI: 10.1016/s2213-2600(17)30342-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 08/15/2017] [Indexed: 10/18/2022]
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Fernandes TM, Poch DS, Auger WR. Treatment of Chronic Thromboembolic Pulmonary Hypertension: The Role of Medical Therapy and Balloon Pulmonary Angioplasty. Methodist Debakey Cardiovasc J 2017; 12:205-212. [PMID: 28289495 DOI: 10.14797/mdcj-12-4-205] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially curable disease when treated with pulmonary thromboendarterectomy (PTE). However, even at experienced surgical centers, nearly one-third of patients with CTEPH will be deemed inoperable for reasons including distal disease, comorbidities, or out-of-proportion pulmonary hypertension. It is in these patients with inoperable CTEPH that pulmonary hypertension (PH)-targeted medical therapy and balloon pulmonary angioplasty have potential therapeutic value. Previous unblinded cohort trials have assessed PH-targeted medical therapy in various subpopulations of CTEPH patients using epoprostenol, treprostinil, sildenafil, bosentan, and iloprost, each demonstrating measurable pulmonary hemodynamic effects. However, riociguat, a soluble guanylate cyclase stimulator, is the first FDA-approved therapy for inoperable CTEPH to demonstrate both an improvement in functional capabilities (6-minute walk time) as well as significant gains in secondary pulmonary hemodynamic end points in a large placebo-controlled trial. Balloon pulmonary angioplasty is an interventional procedure using telescoping catheters placed in the pulmonary arteries, through which wires and balloons are used to mechanically disrupt chronic clot material and relieve pulmonary vascular obstruction. Contemporary case series from multiple centers worldwide have demonstrated pulmonary hemodynamic improvement with this approach. As a result of these advances, patients with inoperable CTEPH who had few options as recently as 5 years ago now have alternatives with emerging evidence of therapeutic efficacy.
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Affiliation(s)
- Timothy M Fernandes
- University of California-San Diego, School of Medicine, La Jolla, California
| | - David S Poch
- University of California-San Diego, School of Medicine, La Jolla, California
| | - William R Auger
- University of California-San Diego, School of Medicine, La Jolla, California
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Pepke-Zaba J, Ghofrani HA, Hoeper MM. Medical management of chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2017; 26:26/143/160107. [DOI: 10.1183/16000617.0107-2016] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 02/14/2017] [Indexed: 02/07/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) results from incomplete resolution of acute pulmonary emboli, organised into fibrotic material that obstructs large pulmonary arteries, and distal small-vessel arteriopathy. Pulmonary endarterectomy (PEA) is the treatment of choice for eligible patients with CTEPH; in expert centres, PEA has low in-hospital mortality rates and excellent long-term survival. Supportive medical therapy consists of lifelong anticoagulation plus diuretics and oxygen, as needed.An important recent advance in medical therapy for CTEPH is the arrival of medical therapies for patients with inoperable disease or persistent/recurrent pulmonary hypertension after PEA. The soluble guanylate cyclase stimulator riociguat is licensed for the treatment of CTEPH in patients with inoperable disease or with recurrent/persistent pulmonary hypertension after PEA. Clinical trials of this agent have shown improvements in patients' haemodynamics and exercise capacity. Phosphodiesterase-5 inhibitors, endothelin receptor antagonists and prostanoids have been used in the treatment of CTEPH, but evidence of benefit is limited. Challenges in the future development of medical therapy for CTEPH include better understanding of the underlying pathology, end-points to monitor the condition's progress, and the optimisation of pulmonary arterial hypertension therapies in relation to diverse patient characteristics and emerging options such as balloon pulmonary angioplasty.
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López Gude MJ, Pérez de la Sota E, Pérez Vela JL, Centeno Rodríguez J, Muñoz Guijosa C, Velázquez MT, Alonso Chaterina S, Hernández González I, Escribano Subías P, Cortina Romero JM. Pulmonary endarterectomy outputs in chronic thromboembolic pulmonary hypertension. Med Clin (Barc) 2017; 149:1-8. [PMID: 28233561 DOI: 10.1016/j.medcli.2016.12.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 12/03/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Pulmonary thromboendarterectomy surgery is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension; extremely high pulmonary vascular resistance constitutes a risk factor for hospital mortality. The objective of this study was to analyze the immediate and long-term results of the surgical treatment of chronic thromboembolic pulmonary hypertension in patients with very severe pulmonary hypertension. MATERIAL AND METHODS Since February 1996, we performed 160 pulmonary thromboendarterectomies. We divided the patient population in 2 groups: group 1, which included 40 patients with pulmonary vascular resistance≥1090dyn/sec/cm-5, and group 2, which included the remaining 120 patients. RESULTS Hospital mortality (15 vs. 2.5%), reperfusion pulmonary edema (33 vs. 14%) and heart failure (23 vs. 3.3%) were all higher in group 1; however, after one year of follow-up, there were no significant differences in the clinical, hemodynamic and echocardiographic conditions of both groups. Survival rate after 5 years was 77% in group 1 and 92% in group 2 (P=.033). After the learning curve including the 46 first patients, there was no difference in hospital mortality (3.8 vs. 2.3%) or survival rate after 5 years (96.2% in group 1 and 96.2% in group 2). CONCLUSIONS Pulmonary thromboendarterectomy is linked to significantly higher morbidity and mortality rates in patients with severe chronic thromboembolic pulmonary hypertension. Nevertheless, these patients benefit the same from the procedure in the mid-/long-term. In our experience, after the learning curve, this surgery is safe in severe pulmonary hypertension and no level of pulmonary vascular resistance should be an absolute counter-indication for this surgery.
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Affiliation(s)
- María Jesús López Gude
- Unidad Multidisciplinar de Hipertensión Pulmonar, Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, España.
| | - Enrique Pérez de la Sota
- Unidad Multidisciplinar de Hipertensión Pulmonar, Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - Jose Luís Pérez Vela
- Unidad Multidisciplinar de Hipertensión Pulmonar, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - Jorge Centeno Rodríguez
- Unidad Multidisciplinar de Hipertensión Pulmonar, Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - Christian Muñoz Guijosa
- Unidad Multidisciplinar de Hipertensión Pulmonar, Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - María Teresa Velázquez
- Unidad Multidisciplinar de Hipertensión Pulmonar, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - Sergio Alonso Chaterina
- Unidad Multidisciplinar de Hipertensión Pulmonar, Servicio de Radiología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - Ignacio Hernández González
- Unidad Multidisciplinar de Hipertensión Pulmonar, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - Pilar Escribano Subías
- Unidad Multidisciplinar de Hipertensión Pulmonar, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - José María Cortina Romero
- Unidad Multidisciplinar de Hipertensión Pulmonar, Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, España
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Charalampopoulos A, Gibbs JSR, Davies RJ, Gin-Sing W, Murphy K, Sheares KK, Pepke-Zaba J, Jenkins DP, Howard LS. Exercise physiological responses to drug treatments in chronic thromboembolic pulmonary hypertension. J Appl Physiol (1985) 2016; 121:623-8. [PMID: 27418685 DOI: 10.1152/japplphysiol.00087.2016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 07/06/2016] [Indexed: 11/22/2022] Open
Abstract
We tested the hypothesis that patients with chronic thromboembolic pulmonary hypertension (CTEPH) that was deemed to be inoperable were more likely to respond to drugs for treating pulmonary arterial hypertension (PAH) by using cardiopulmonary exercise (CPX) testing than those with CTEPH that was deemed to be operable. We analyzed CPX testing data of all patients with CTEPH who were treated with PAH drugs and had undergone CPX testing before and after treatment at a single pulmonary hypertension center between February 2009 and March 2013. Suitability for pulmonary endarterectomy (PEA) was decided by experts in PEA who were associated with a treatment center. The group with inoperable CTEPH included 16 patients, the operable group included 26 patients. There were no differences in demographics and baseline hemodynamic data between the groups. Unlike patients in the operable group, after drug treatment patients with inoperable CTEPH had a significantly higher peak V̇o2 (P < 0.001), work load (P = 0.002), and oxygen pulse (P < 0.001). In terms of gas exchange, there was an overall net trend toward improved V̇e/V̇co2 in the group with inoperable CTEPH, with an increased PaCO2 (P = 0.01), suggesting reduced hyperventilation. No changes were observed in patients with operable CTEPH. In conclusion, treatment with PAH drug therapy reveals important pathophysiological differences between inoperable and operable CTEPH, with significant pulmonary vascular and cardiac responses in inoperable disease. Drug effects on exercise function observed in inoperable CTEPH cannot be translated to all forms of CTEPH.
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Affiliation(s)
- Athanasios Charalampopoulos
- National Pulmonary Hypertension Service, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - J Simon R Gibbs
- National Pulmonary Hypertension Service, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom; National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Rachel J Davies
- National Pulmonary Hypertension Service, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Wendy Gin-Sing
- National Pulmonary Hypertension Service, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Kevin Murphy
- Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Karen K Sheares
- Pulmonary Vascular Diseases Unit, Papworth Hospital, Cambridge, United Kingdom; and
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Papworth Hospital, Cambridge, United Kingdom; and
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, United Kingdom
| | - Luke S Howard
- National Pulmonary Hypertension Service, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom; National Heart & Lung Institute, Imperial College London, London, United Kingdom;
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Delcroix M, Lang I, Pepke-Zaba J, Jansa P, D'Armini AM, Snijder R, Bresser P, Torbicki A, Mellemkjaer S, Lewczuk J, Simkova I, Barberà JA, de Perrot M, Hoeper MM, Gaine S, Speich R, Gomez-Sanchez MA, Kovacs G, Jaïs X, Ambroz D, Treacy C, Morsolini M, Jenkins D, Lindner J, Dartevelle P, Mayer E, Simonneau G. Long-Term Outcome of Patients With Chronic Thromboembolic Pulmonary Hypertension: Results From an International Prospective Registry. Circulation 2016; 133:859-71. [PMID: 26826181 DOI: 10.1161/circulationaha.115.016522] [Citation(s) in RCA: 434] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 01/19/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension, a rare complication of acute pulmonary embolism, is characterized by fibrothrombotic obstructions of large pulmonary arteries combined with small-vessel arteriopathy. It can be cured by pulmonary endarterectomy, and can be clinically improved by medical therapy in inoperable patients. A European registry was set up in 27 centers to evaluate long-term outcome and outcome correlates in 2 distinct populations of operated and not-operated patients who have chronic thromboembolic pulmonary hypertension. METHODS AND RESULTS A total of 679 patients newly diagnosed with chronic thromboembolic pulmonary hypertension were prospectively included over a 24-month period. Estimated survival at 1, 2, and 3 years was 93% (95% confidence interval [CI], 90-95), 91% (95% CI, 87-93), and 89% (95% CI, 86-92) in operated patients (n=404), and only 88% (95% CI, 83-91), 79% (95% CI, 74-83), and 70% (95% CI, 64-76) in not-operated patients (n=275). In both operated and not-operated patients, pulmonary arterial hypertension-targeted therapy did not affect survival estimates significantly. Mortality was associated with New York Heart Association functional class IV (hazard ratio [HR], 4.16; 95% CI, 1.49-11.62; P=0.0065 and HR, 4.76; 95% CI, 1.76-12.88; P=0.0021), increased right atrial pressure (HR, 1.34; 95% CI, 0.95-1.90; P=0.0992 and HR, 1.50; 95% CI, 1.20-1.88; P=0.0004), and a history of cancer (HR, 3.02; 95% CI, 1.36-6.69; P=0.0065 and HR, 2.15; 95% CI, 1.18-3.94; P=0.0129) in operated and not-operated patients, respectively. Additional correlates of mortality were bridging therapy with pulmonary arterial hypertension-targeted drugs, postoperative pulmonary hypertension, surgical complications, and additional cardiac procedures in operated patients, and comorbidities such as coronary disease, left heart failure, and chronic obstructive pulmonary disease in not-operated patients. CONCLUSIONS The long-term prognosis of operated patients currently is excellent and better than the outcome of not-operated patients.
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Affiliation(s)
- Marion Delcroix
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.).
| | - Irene Lang
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Joanna Pepke-Zaba
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Pavel Jansa
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Andrea M D'Armini
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Repke Snijder
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Paul Bresser
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Adam Torbicki
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Sören Mellemkjaer
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Jerzy Lewczuk
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Iveta Simkova
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Joan A Barberà
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Marc de Perrot
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Marius M Hoeper
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Sean Gaine
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Rudolf Speich
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Miguel A Gomez-Sanchez
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Gabor Kovacs
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Xavier Jaïs
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - David Ambroz
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Carmen Treacy
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Marco Morsolini
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - David Jenkins
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Jaroslav Lindner
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Philippe Dartevelle
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Eckhard Mayer
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
| | - Gérald Simonneau
- From KU Leuven - University of Leuven, University Hospitals of Leuven, Belgium (M.D.); Medical University of Vienna, Austria (I.L.); Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T., D.J.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague; Czech Republic (P.J., D.A., J.L.); San Matteo Hospital, University of Pavia, Italy (A.M.D., M.M.); St Antonius Ziekenhuis, Nieuwegein, The Netherlands (R.S.); OLVG, Amsterdam, The Netherlands (P.B.); Medical Center for Postgraduate Education, ECZ-Otwock, Poland (A.T.); Aarhus University Hospital, Skejby, Denmark (S.M.); Regional Specialist Hospital and Medical University, Wroclaw, Poland (J.L.); Slovak Medical University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia (I.S.); Hospital Clínic- IDIBAPS-CIBER Enfermedades Respiratorias, Universtiy of Barcelona, Spain (J.A.B.); Toronto General Hospital, Canada (M.d.P.); Medizinische Hochschule Hannover, Germany, and German Center of Lung Research (DZL), Hannover, Germany (M.M.H.); Mater Misericordiae University Hospital, Dublin, Ireland (S.G.); Universitätspital Zürich, Switzerland (R.S.); Hospital Universitario 12 Octubre-CIBER Enfermedades Respiratorias, Madrid, Spain (M.A.G.-S.); Medical University of Graz, Austria and Ludwig Boltzmann Institute for Lung Vascular Research, Austria (G.K.); University Paris Sud (Paris XI), INSERM U 999, Hôpital Le Kremlin Bicêtre, France (X.J., P.D., G.S.); and Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.)
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Abstract
PURPOSE OF REVIEW Chronic thromboembolic pulmonary hypertension (CTEPH) is an important cause of pulmonary hypertension. Although surgery is potentially curative, some patients present with inoperable disease. In these patients, medical therapies for pulmonary arterial hypertension are increasingly being used. RECENT FINDINGS The pathobiology of CTEPH development remains incompletely understood; however, evidence supports both large and small vessel disorder in patients with the disease. Surgical thromboendarterectomy is an increasingly well tolerated and often curative procedure and is the management strategy of choice for most patients. Although excellent outcomes in surgical management have been noted, the role of medical management in selected patients with inoperable or recurrent or persistent disease after surgery is increasing. A recent large, randomized controlled clinical trial of riociguat in CTEPH demonstrated improvements in exercise capacity, functional class, and hemodynamics. A safe, effective angioplasty approach to CTEPH is being pursued in addition. SUMMARY The approach to CTEPH management in the operable patient remains surgical, without clear benefit to preoperative pulmonary arterial hypertension-specific therapy at this time. Patients with inoperable disease or pulmonary hypertension following thromboendarterectomy, however, should be considered for medical management, with riociguat currently having the strongest evidence specific to CTEPH.
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Perspectives on oral pulmonary hypertension therapies recently approved by the U.S. Food and Drug Administration. Ann Am Thorac Soc 2015; 12:269-73. [PMID: 25590376 DOI: 10.1513/annalsats.201501-020as] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In the past 18 months, the U.S. Food and Drug Administration approved macitentan, riociguat, and treprostinil as oral agents for the treatment of pulmonary arterial hypertension (PAH); riociguat also became the first agent approved for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH). These new agents are welcome additional therapeutic options for PAH and CTEPH. However, their use can be complicated by potential drug interactions, adverse effects, dosing complexity, and cost. Macitentan, the newest endothelin receptor antagonist, showed significant benefits in a long-term event-driven trial of morbidity and mortality. Dosed once daily and with minimal liver toxicity, it has potential drug interactions with potent CYP 3A4 inhibitors and inducers, and can decrease hemoglobin levels. Riociguat is approved for PAH and clinically inoperable CTEPH to improve exercise capacity and functional status. Riociguat requires dose titration beginning with 1 mg up to 2.5 mg three times a day, as tolerated, and should be used with caution in patients with underlying risk factors for systemic hypotension. Oral treprostinil, approved to improve exercise capacity in PAH, is associated with gastrointestinal side effects and headaches that are often dose limiting. Doses can begin with 0.125 mg or 0.25 mg twice a day with gradual increases on up to a weekly basis, as tolerated. Thrice daily dosing and administration with a meal can improve tolerance. These newer agents represent advances, but their specific roles in relation to pre-existing therapies are undergoing further evaluation. Therefore, close collaboration with clinicians at centers with therapeutic expertise is highly recommended to optimize patient outcomes.
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Hadinnapola C, Pepke-Zaba J. Developments in pulmonary arterial hypertension-targeted therapy for chronic thromboembolic pulmonary hypertension. Expert Rev Respir Med 2015; 9:559-69. [PMID: 26366805 DOI: 10.1586/17476348.2015.1085805] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease characterised by the presence of organised chronic thromboembolic material occluding the proximal pulmonary arteries and a vasculopathy in the distal pulmonary arterial tree. Pulmonary endarterectomy (PEA) is a potential cure for many patients with CTEPH. However, PEA is not suitable for patients with a significant distal distribution of chronic thromboembolic material or with significant comorbidities. Also, a proportion of patients are left with residual CTEPH post PEA. Until recently, pulmonary arterial hypertension-targeted therapies have been used off licence to treat patients with inoperable or residual CTEPH. The CHEST1 study investigated the use of riociguat and was the first randomised controlled trial to show efficacy in inoperable or residual CTEPH. In this review, we explore the pathophysiology of CTEPH and review the current trial evidence for pulmonary arterial hypertension-targeted therapies. We also include a discussion of physiological considerations that require further investigation.
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Affiliation(s)
- Charaka Hadinnapola
- a Pulmonary Vascular Diseases Unit, Papworth Hospital, Papworth Everard, Cambridge, CB23 3RE, UK
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Use of outcome measures in pulmonary hypertension clinical trials. Am Heart J 2015; 170:419-29.e3. [PMID: 26385024 DOI: 10.1016/j.ahj.2015.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 06/16/2015] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To evaluate the use of surrogate measures in pulmonary hypertension (PH) clinical trials and how it relates to clinical practice. BACKGROUND Studies of pulmonary arterial hypertension (PAH) employ a variety of surrogate measures in addition to clinical events because of a small patient population, participant burden, and costs. The use of these measures in PH drug trials is poorly defined. METHODS We searched PubMed/MEDLINE/Embase for randomized or prospective cohort PAH clinical treatment trials from 1985 to 2013. Extracted data included intervention, trial duration, study design, patient characteristics, and primary and secondary outcome measures. To compare with clinical practice, we assessed the use of surrogate measures in a clinical sample of patients on PH medications at Duke University Medical Center between 2003 and 2014. RESULTS Between 1985 and 2013, 126 PAH trials were identified and analyzed. Surrogate measures served as primary endpoints in 119 trials (94.0%). Inclusion of invasive hemodynamics decreased over time (78.6%, 75.0%, 52.2%; P for trend = .02), while functional testing (7.1%, 60.0%, 81.5%; P for trend < .0001) and functional status or quality of life (0%, 47.6%, 62.8%; P for trend < .0001) increased in PAH trials over the same time periods. Echocardiography data were reported as a primary or secondary outcome in 32 trials (25.4%) with increased use from 1985-1994 to 1995-2004 (7.1% vs 35.0%, P = .04), but the trend did not continue to 2005-2013 (25.0%). In comparison, among 450 patients on PAH therapies at our institution between 2003 and 2013, clinical assessments regularly incorporated serial echocardiography and 6-minute walk distance tests (92% and 95% of patients, respectively) and repeat measurement of invasive hemodynamics (46% of patients). CONCLUSIONS The majority of PAH trials have utilized surrogate measures as primary endpoints. The use of these surrogate endpoints has evolved significantly over time with increasing use of patient-centered endpoints and decreasing or stable use of imaging and invasive measures. In contrast, imaging and invasive measures are commonly used in contemporary clinical practice. Further research is needed to validate and standardize currently used measures.
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Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, Ghofrani A, Gomez Sanchez MA, Hansmann G, Klepetko W, Lancellotti P, Matucci M, McDonagh T, Pierard LA, Trindade PT, Zompatori M, Hoeper M. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2015; 46:903-75. [DOI: 10.1183/13993003.01032-2015] [Citation(s) in RCA: 1929] [Impact Index Per Article: 214.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Guidelines summarize and evaluate all available evidence on a particular issue at the time of the writing process, with the aim of assisting health professionals in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines and recommendations should help health professionals to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.
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Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, Ghofrani A, Gomez Sanchez MA, Hansmann G, Klepetko W, Lancellotti P, Matucci M, McDonagh T, Pierard LA, Trindade PT, Zompatori M, Hoeper M. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2015; 37:67-119. [DOI: 10.1093/eurheartj/ehv317] [Citation(s) in RCA: 3916] [Impact Index Per Article: 435.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Kim NH, Mayer E. Chronic thromboembolic pulmonary hypertension: the evolving treatment landscape. Eur Respir Rev 2015; 24:173-7. [DOI: 10.1183/16000617.00001515] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Schölzel BE, Snijder RJ, Mager JJ, van Es HW, Plokker HWM, Reesink HJ, Morshuis WJ, Post MC. Chronic thromboembolic pulmonary hypertension. Neth Heart J 2014; 22:533-41. [PMID: 25169577 PMCID: PMC4391185 DOI: 10.1007/s12471-014-0592-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Chronic pulmonary thromboembolic disease is an important cause of severe pulmonary hypertension, and as such is associated with significant morbidity and mortality. The prognosis of this condition reflects the degree of associated right ventricular dysfunction, with predictable mortality related to the severity of the underlying pulmonary hypertension. Left untreated, the prognosis is poor. Pulmonary endarterectomy is the treatment of choice to relieve pulmonary artery obstruction in patients with chronic thromboembolic pulmonary hypertension and has been remarkably successful. Advances in surgical techniques along with the introduction of pulmonary hypertension-specific medication provide therapeutic options for the majority of patients afflicted with the disease. However, a substantial number of patients are not candidates for pulmonary endarterectomy due to either distal pulmonary vascular obstruction or significant comorbidities. Therefore, careful selection of surgical candidates in expert centres is paramount. The current review focuses on the diagnostic approach to chronic thromboembolic pulmonary hypertension and the available surgical and medical therapeutic options.
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Affiliation(s)
- B. E. Schölzel
- Department of Cardiology, Amphia Hospital, Molengracht 21, 4818 CK Breda, the Netherlands
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - R. J. Snijder
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - J. J. Mager
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - H W. van Es
- Department of Radiology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - H. W. M. Plokker
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - H. J. Reesink
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - W. J. Morshuis
- Department of Cardio-Thoracic Surgery, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - M. C. Post
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
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Affiliation(s)
- Irene Marthe Lang
- From the Department of Internal Medicine II, Division of Cardiology, Vienna, Austria (I.M.L.); and Department of Surgery, Division of Cardiovascular and Thoracic Surgery, University of California–San Diego, La Jolla (M.M.)
| | - Michael Madani
- From the Department of Internal Medicine II, Division of Cardiology, Vienna, Austria (I.M.L.); and Department of Surgery, Division of Cardiovascular and Thoracic Surgery, University of California–San Diego, La Jolla (M.M.)
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Hoeper MM, Madani MM, Nakanishi N, Meyer B, Cebotari S, Rubin LJ. Chronic thromboembolic pulmonary hypertension. THE LANCET RESPIRATORY MEDICINE 2014; 2:573-82. [PMID: 24898750 DOI: 10.1016/s2213-2600(14)70089-x] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but debilitating and life-threatening complication of acute pulmonary embolism. CTEPH results from persistent obstruction of pulmonary arteries and progressive vascular remodelling. Not all patients presenting with CTEPH have a history of clinically overt pulmonary embolism. The diagnostic work-up to detect or rule out CTEPH should include ventilation-perfusion scintigraphy, which has high sensitivity and a negative predictive value of nearly 100%. CT angiography usually reveals typical features of CTEPH, including mosaic perfusion, part or complete occlusion of pulmonary arteries, and intraluminal bands and webs. Patients with suspected CTEPH should be referred to a specialist centre for right-heart catheterisation and pulmonary angiography. Surgical pulmonary endarterectomy remains the treatment of choice for CTEPH and is associated with excellent long-term results and a high probability of cure. For patients with inoperable CTEPH, various medical and interventional therapies are being developed.
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Affiliation(s)
- Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School and German Centre for Lung Research (DZL), Hannover, Germany.
| | - Michael M Madani
- Department of Cardiothoracic Surgery, University of California, San Diego, CA, USA
| | - Norifumi Nakanishi
- Department of Cardiovascular Medicine, National Cardiovascular Centre, Osaka, Japan
| | - Bernhard Meyer
- Department of Radiology, Hannover Medical School, Hannover, Germany
| | - Serghei Cebotari
- Department of Cardiovascular, Thoracic and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Lewis J Rubin
- Department of Respiratory Medicine, University of California, San Diego, CA, USA
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Hepatotoxicidad en pacientes tratados con antagonistas del receptor de la endotelina: revisión sistemática y metaanálisis de ensayos clínicos aleatorizados. Med Clin (Barc) 2014; 142:333-42. [DOI: 10.1016/j.medcli.2013.01.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 12/19/2012] [Accepted: 01/10/2013] [Indexed: 12/31/2022]
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47
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a disease with high mortality and few treatment options. This article reviews the epidemiology of CTEPH and identifies risk factors for its development. The pathobiology and the progression from thromboembolic events to chronically increased right-sided pressures are discussed. The diagnosis and assessment of CTEPH requires several modalities and the role of these is detailed. The pre-operative evaluation assesses peri-operative risk and determines the likelihood of benefit from PTE. Pulmonary thromboendarterectomy (PTE) remains the treatment of choice in appropriate patients. Nonsurgical therapies for CTEPH may provide benefit in patients who cannot be offered surgery.
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Affiliation(s)
- Peter S Marshall
- Yale University School of Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, 15 York Street, LCI 101, New Haven, CT 06510, USA.
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48
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Surie S, Reesink HJ, Marcus JT, van der Plas MN, Kloek JJ, Vonk-Noordegraaf A, Bresser P. Bosentan treatment is associated with improvement of right ventricular function and remodeling in chronic thromboembolic pulmonary hypertension. Clin Cardiol 2013; 36:698-703. [PMID: 24037998 DOI: 10.1002/clc.22197] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 07/15/2013] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Medical pretreatment before pulmonary endarterectomy (PEA) can optimize right ventricular (RV) function and may improve postoperative outcome in high-risk patients. Using cardiac magnetic resonance imaging (cMRI), we determined whether the dual endothelin-1 antagonist bosentan improves RV function and remodeling in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who waited for PEA. HYPOTHESIS We hypothesized that medical therapy prior to PEA will be associated with improvements in RV remodeling and function. METHODS In this pilot study, 15 operable CTEPH patients were randomly assigned to either bosentan (n = 8) or no bosentan (n = 7, control) for 16 weeks, next to "best standard of care." Both before and after treatment, RV stroke volume index (RVSVI), RV ejection fraction (RVEF), RV mass, RV isovolumic relaxation time (rIVRT), leftward ventricular septal bowing (LVSB), and left ventricular ejection fraction (LVEF) were determined using cMRI. RESULTS After 16 weeks, the change (Δ) from baseline (median [range]) in the studied cMRI parameters differed significantly between the bosentan group and the controls: Δ RVSVI: 6 [-4-11] vs 1 [-6-3] mL/m(-2) ; Δ RVEF: 8 [-10-15] vs -4 [-7-5]%; Δ RV mass: -3 [-6--2] vs 2 [-1-3] g/m(-2) ; Δ rIVRT: -30 [-130-20] vs 10 [-30-30] msec; Δ LVSB: 0.03 [-0.03-0.13] vs -0.03[-0.08-0.04] cm(-1) ; and Δ LVEF: 8 [-5-17] vs -2 [-14-2]% (all P < 0.05). The change from baseline in mean pulmonary artery pressure (-11 [-17-11] vs 5 [-6-21] mm Hg, P < 0.05) and 6-minute walk distance (20 [3-88] vs -4 [-40-40] m, P < 0.05) also differed significantly. CONCLUSIONS In CTEPH, compared with control, treatment with bosentan for 16 weeks was associated with a significant improvement in cMRI parameters of RV function and remodelling.
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Affiliation(s)
- Sulaiman Surie
- Departments of Pulmonology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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49
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Liu C, Chen J, Gao Y, Deng B, Liu K. Endothelin receptor antagonists for pulmonary arterial hypertension. Cochrane Database Syst Rev 2013; 2013:CD004434. [PMID: 23450552 PMCID: PMC6956416 DOI: 10.1002/14651858.cd004434.pub5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension is a devastating disease, which leads to right heart failure and premature death. Recent evidence suggests that endothelin receptor antagonists may be promising drugs in the treatment of pulmonary arterial hypertension. OBJECTIVES To evaluate the efficacy of endothelin receptor antagonists in pulmonary arterial hypertension. SEARCH METHODS We searched CENTRAL (Cochrane Central Register of Controlled Trials), MEDLINE, EMBASE, and the reference section of retrieved articles. Searches are current as of January 2012. SELECTION CRITERIA We included randomised trials (RCTs) and quasi-randomised trials involving patients with pulmonary arterial hypertension. DATA COLLECTION AND ANALYSIS Five review authors independently selected studies, assessed study quality and extracted data. MAIN RESULTS We included 12 randomised controlled trials involving 1471 patients. All the trials were of relatively short duration (12 weeks to six months). After treatment, patients treated with endothelin receptor antagonists could walk on average 33.71 metres (95% confidence interval (CI) 24.90 to 42.52 metres) further than those treated with placebo in a six-minute walk test. Endothelin receptor antagonists improved more patients' World Health Organization/New York Heart Association (WHO/NYHA) functional class status than placebo (odds ratio (OR) 1.60; 95% CI 1.20 to 2.14), and reduced the odds of functional class deterioration compared with placebo (OR 0.26; 95% CI 0.16 to 0.42). There was a reduction in mortality that did not reach statistical significance on endothelin receptor antagonists (OR 0.57; 95% CI 0.26 to 1.24), and limited data suggest that endothelin receptor antagonists improve the Borg dyspnoea score and cardiopulmonary haemodynamics in symptomatic patients. Hepatic toxicity was not common, and endothelin receptor antagonists were well tolerated in this population. However, several cases of irreversible liver failure caused by sitaxsentan have been reported that led to license holder for sitaxsentan to withdraw the product from all markets worldwide. AUTHORS' CONCLUSIONS Endothelin receptor antagonists can increase exercise capacity, improve WHO/NYHA functional class, prevent WHO/NYHA functional class deterioration, reduce dyspnoea and improve cardiopulmonary haemodynamic variables in patients with pulmonary arterial hypertension with WHO/NYHA functional class II and III. However, there was only a trend towards endothelin receptor antagonists reducing mortality in patients with pulmonary arterial hypertension. Efficacy data are strongest in those with idiopathic pulmonary hypertension. The irreversible liver failure caused by sitaxsentan and its withdrawal from global markets emphasise the importance of hepatic monitoring in patients treated with endothelin receptor antagonists.
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Affiliation(s)
- Chao Liu
- The First Hospital of Hebei Medical University, Shijiazhuang, China. .
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50
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Successful pulmonary endarterectomy in a patient with klinefelter syndrome. Case Rep Pulmonol 2013; 2012:104195. [PMID: 23304604 PMCID: PMC3530858 DOI: 10.1155/2012/104195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Accepted: 11/26/2012] [Indexed: 11/18/2022] Open
Abstract
Klinefelter syndrome (KS) is a frequent genetic disorder due to one or more supernumerary X chromosomes. KS is associated with an increased risk for venous thromboembolic events like deep venous thrombosis and pulmonary embolism. This paper describes a 37-year-old male patient with KS referred to our tertiary center with chronic thromboembolic pulmonary hypertension, and who was successfully treated by pulmonary endarterectomy.
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