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Wiedenroth CB, Bandorski D, Ariobi K, Ghofrani HA, Lankeit M, Liebetrau C, Pruefer D, Mayer E, Kriechbaum SD, Guth S. Does Age Matter? Pulmonary Endarterectomy in the Elderly Patient with CTEPH. Thorac Cardiovasc Surg 2022; 70:663-670. [PMID: 35038757 DOI: 10.1055/s-0041-1740559] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The gold standard treatment of patients with chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary endarterectomy (PEA). Little is known about the influence of advanced age on surgical outcome. Therefore, the aim of this study was to investigate the impact of patient's age on postoperative morbidity, mortality, and quality of life in a German referral center. METHODS Prospectively collected data from 386 consecutive patients undergoing PEA between 01/2014 and 12/2016 were analyzed. Patients were divided into three groups according to their age: group 1: ≤ 50 years, group 2: > 50 ≤ 70 years, group 3: > 70 years. RESULTS After PEA, distinct improvements in pulmonary hemodynamics, physical capacity (World Health Organization [WHO] functional class and 6-minute walking distance) and quality of life were found in all groups. There were more complications in elderly patients with longer time of invasive ventilation, intensive care, and in-hospital stay. However, the in-hospital mortality was comparable (0% in group 1, 2.6% in group 2, and 2.1% in group 3 [p = 0.326]). Furthermore, the all-cause mortality at 1 year was 1.1% in group 1, 3.2% in group 2, and 6.3% in group 3 (p = 0.122). CONCLUSIONS PEA is an effective treatment for CTEPH patients of all ages accompanied by low perioperative and 1-year mortality. CTEPH patients in advanced age carefully selected by thorough preoperative evaluation should be offered PEA in expert centers to improve quality of life, symptoms, and pulmonary hemodynamics.
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Affiliation(s)
| | - Dirk Bandorski
- Faculty of Medicine, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Kanischka Ariobi
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - H-Ardeschir Ghofrani
- Department of Pulmonology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany.,Department of Medicine, Imperial College, London, United Kingdom
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Germany Clinic for Cardiology and Pneumology, University Medical Center Göttingen, Germany
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Frankfurt am Main, Germany.,Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | - Diethard Pruefer
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Steffen D Kriechbaum
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Frankfurt am Main, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
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2
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Tanabe N, Fukuda K, Matsubara H, Nakanishi N, Tahara N, Ikeda S, Kishi T, Satoh T, Hirata KI, Inoue T, Kimura H, Okano Y, Okazaki O, Sata M, Tsujino I, Ueno S, Yamada N, Yao A, Kuriyama T. Selexipag for Chronic Thromboembolic Pulmonary Hypertension in Japanese Patients - A Double-Blind, Randomized, Placebo-Controlled, Multicenter Phase II Study. Circ J 2020; 84:1866-1874. [PMID: 32879152 DOI: 10.1253/circj.cj-20-0438] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Selexipag is an oral prostacyclin receptor (IP receptor) agonist with a non-prostanoid structure. This study examined its efficacy and safety in Japanese patients with non-operated or persistent/recurrent chronic thromboembolic pulmonary hypertension (CTEPH).Methods and Results:This Phase II study was a randomized, double-blind, placebo-controlled parallel-group comparison. The primary endpoint was a change in pulmonary vascular resistance (PVR) from baseline to week 17. The main analysis involved a per-protocol set group of 28 subjects. The change in PVR (mean±SD) after 17 weeks of treatment in the selexipag group was -104±191 dyn·s/cm5, whereas that in the placebo group was 26±180 dyn·s/cm5. Thus, the treatment effect after 17 weeks of selexipag treatment was calculated as -130±189 dyn·s/cm5(P=0.1553). Although the primary endpoint was not met, for the group not concomitantly using a pulmonary vasodilator the PVR in the selexipag group was significantly decreased compared with placebo group (P=0.0364). The selexipag group also showed improvement in total pulmonary resistance and cardiac index. CONCLUSIONS Selexipag treatment improved pulmonary hemodynamics in Japanese patients with CTEPH, but PVR did not show a significant difference between the selexipag and placebo groups. (Trial registration: JAPIC Clinical Trials Information [JapicCTI-111667]).
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Affiliation(s)
- Nobuhiro Tanabe
- Department of Respirology, Graduate School of Medicine, Chiba University
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine
| | - Hiromi Matsubara
- Director of Entire Medical Departments, National Hospital Organization Okayama Medical Center
| | | | - Nobuhiro Tahara
- Department of Medicine, Division of Cardiovascular Medicine, Kurume University School of Medicine
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Takuya Kishi
- Department of Cardiology, Graduate School of Medical Sciences, International University of Health and Welfare
| | - Toru Satoh
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Ken-Ichi Hirata
- Cardiovascular Medicine, Kobe University Graduate School of Medicine
| | - Teruo Inoue
- Department of Cardiovascular Medicine, Dokkyo Medical University School of Medicine
| | | | - Yoshiaki Okano
- Department of Intermal Medicine, Hanwa Dai-ni Senboku Hospital
| | - Osamu Okazaki
- Department of Cardiology, National Center for Global Health and Medecine
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | - Ichizo Tsujino
- The First Department of Medicine, Hokkaido University School of Medicine
| | - Shuichi Ueno
- Department of Internal Medicine Division of Cardiovascular Medicine, Jichi Medical University School of Medicine.,Ueno Clinic
| | | | - Atsushi Yao
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
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Puis L, Vandezande E, Vercaemst L, Janssens P, Taverniers Y, Foulon M, Demeyere R, Delcroix M, Daenen W. Pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension. Perfusion 2017; 20:101-8. [PMID: 15918447 DOI: 10.1191/0267659105pf791oa] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Introduction. Pulmonary thromboendarterectomy (PTE) is a surgical procedure which is considered the only effective and potentially curative treatment for chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH is a rare outcome from pulmonary emboli and, when left untreated, will result in right ventricular failure and death. Methods. From June 1999 to November 2003, 40 of these procedures were performed in our institution. Emphasis is placed on multidisciplinarity and cooperation between different medical and surgical disciplines. Perfusion management consists of myocar-dial and cerebral protection, deep hypothermia with multiple periods of circulatory arrest, reperfusion at hypothermia, hemofiltration and cellsaving techniques. Results. Hemodynamic improvement occurs immediately post operation. Mean pulmonary artery pressure decreased from 50±11 to 38±10 mmHg, pulmonary vascular resistance from 1246±482 to 515±294 dynes s/cm5 and cardiac index increased from 1.54±0.54 to 2.63±0.75 L/min per m2. Pump runs had an average duration of 187±29 min, circulatory arrest time was 29±11 min and crossclamp time 36±14 min. Extracorporeal membrane oxygenation can be an ultimate treatment for specific postoperative problems like persistent pulmonary hypertension and/or reperfusion pulmonary edema.
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Affiliation(s)
- Luc Puis
- Department of Extra Corporeal Circulation, UZ Gasthuisberg, KU Leuven, Belgium.
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4
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Nierlich P, Hold A, Ristl R. Outcome after surgical treatment of chronic thromboembolic pulmonary hypertension: dealing with different patient subsets. A single-centre experience. Eur J Cardiothorac Surg 2016; 50:898-906. [DOI: 10.1093/ejcts/ezw099] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 02/22/2016] [Indexed: 11/13/2022] Open
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5
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Ogino H. Recent advances of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension including Japanese experiences. Gen Thorac Cardiovasc Surg 2013; 62:9-18. [DOI: 10.1007/s11748-013-0323-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Indexed: 11/25/2022]
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6
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Sato M, Ando M, Kaneko K, Higuchi Y, Kondo H, Akita K, Ishida M, Takagi Y. Respiratory and hemodynamic changes in patients with chronic thromboembolic pulmonary hypertension 1 year after pulmonary endarterectomy. Ann Vasc Dis 2013; 6:578-82. [PMID: 24130612 DOI: 10.3400/avd.oa.13-00056] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 07/02/2013] [Indexed: 11/13/2022] Open
Abstract
We reviewed the results of thromboembolectomy, which was performed for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH), 1 year after the operation. We obtained hemodynamic and respiratory data of 60 patients from the 112 patients who were operated at our institute. The hemodynamic parameters such as mean pulmonary arterial pressure (PAP), pulmonary vascular resistance (PVR), and cardiac index (CI) were significantly improved after the operation, and this improvement of pulmonary hemodynamics persisted even a year after the operation. A significant improvement in gas exchange was observed immediately after the operation and a further elevation in the partial pressure of oxygen in arterial blood (PaO2) was observed 1 year after the operation. (English Translation of J Jpn Coll Angiol 2012; 52: 53-58).
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Affiliation(s)
- Masato Sato
- Department of Cardiovascular Surgery, Fujita Health University, Toyoake, Aichi, Japan
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7
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Clinical worsening after pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension. Neth Heart J 2011; 19:498-503. [PMID: 21979755 DOI: 10.1007/s12471-011-0203-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Pulmonary endarterectomy (PEA) is the most effective treatment for chronic thromboembolic pulmonary hypertension (CTEPH). The aim of this study is to evaluate long-term survival and freedom from clinical worsening after PEA. METHODS All patients who underwent PEA in our hospital between May 2000 and August 2009 were included. Follow-up parameters were all-cause mortality and time to clinical worsening, defined as a combination of death, need for pulmonary hypertension-specific medication or 15% decrease in six-minute walk distance without improvement in functional class. The Cox proportional hazard regression was used to identify predictors. RESULTS Seventy-four consecutive patients (mean age 55.9 ± 13.8 years, 51% female) underwent PEA. Prior to surgery, 55 patients were in NYHA functional class III or higher. The mean pulmonary artery pressure was 41.3 ± 11.9 mmHg with a mean pulmonary vascular resistance of 521 ± 264 dyn·s·cm(-5) (range 279-1331 dyn·s·cm(-5)). Five patients (6.8%) died in-hospital. Out of hospital, 5 out of 69 patients (7.2%) died during a median follow-up of 3.7 ± 2.2 years [range 0.1-8.5 years]). The one- and five-year survival rates were 93% and 89%, respectively. During follow-up, clinical worsening occurred in 13 out of 69 patients (18.8%). The one- and five-year rates of freedom from clinical worsening were 94% and 72%, respectively. The baseline NT-pro BNP level tended to be a predictor for occurrence of clinical worsening. CONCLUSION Pulmonary endarterectomy is associated with good long-term survival in patients with CTEPH. However, clinical worsening occurred in a substantial number of patients at long-term follow-up.
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8
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Alternatives to Lung Transplantation: Treatment of Pulmonary Arterial Hypertension. Clin Chest Med 2011; 32:399-410. [DOI: 10.1016/j.ccm.2011.02.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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9
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Guidelines for the diagnosis, treatment and prevention of pulmonary thromboembolism and deep vein thrombosis (JCS 2009). Circ J 2011; 75:1258-81. [PMID: 21441695 DOI: 10.1253/circj.cj-88-0010] [Citation(s) in RCA: 220] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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10
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Saouti N, Morshuis WJ, Heijmen RH, Snijder RJ. Long-term outcome after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: a single institution experience. Eur J Cardiothorac Surg 2009; 35:947-52; discussion 952. [DOI: 10.1016/j.ejcts.2009.01.023] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Revised: 01/09/2009] [Accepted: 01/13/2009] [Indexed: 11/30/2022] Open
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11
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Matsuda H, Ogino H, Minatoya K, Sasaki H, Nakanishi N, Kyotani S, Kobayashi J, Yagihara T, Kitamura S. Long-Term Recovery of Exercise Ability After Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension. Ann Thorac Surg 2006; 82:1338-43; discussion 1343. [PMID: 16996930 DOI: 10.1016/j.athoracsur.2006.03.105] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2006] [Revised: 03/29/2006] [Accepted: 03/29/2006] [Indexed: 12/17/2022]
Abstract
BACKGROUND The exercise capacity of patients with thromboembolic pulmonary hypertension was investigated to clarify the long-term effects of pulmonary endarterectomy. This capacity was assessed by measuring cardiopulmonary factors during cardiopulmonary exercise testing at the maximal level of exercise and a 6-minute walk test at the submaximal level. Their survival rate was also determined. METHODS We conducted a retrospective review of the clinical records of 102 patients who underwent pulmonary endarterectomy (63 women; median age, 53 years). RESULTS Eight (7.8%) hospital mortalities were encountered. Three late mortalities due to fulminant hepatitis, breast cancer, and pneumonia in a patient under steroid therapy were unrelated to pulmonary endarterectomy. The actual survival rate including hospital mortalities was 90.9% at 3 years and 84.0% at 5 years. All hemodynamic measurements significantly improved and reached a plateau 1-month after endarterectomy. The cardiopulmonary exercise test at the maximal exercise level revealed that peak oxygen uptake (V(O2)) baseline was 13.8 +/- 3.2 mL/min/kg, and at 1-month was 16.2 +/- 4.2 mL/min/kg (p = 0.0015) and ventilatory response to carbon dioxide production (V(E)-V(CO2)) slope baseline was 46.5 +/- 8.4 mL/min/kg, and at 1-month was 39.9 +/- 7.4 (p = 0.0006), which gradually and significantly improved during the first year after endarterectomy (peak V(O2), 19.9 +/- 3.9 mL/min/kg [p < 0.0001] and V(E)-V(CO2) slope, 33.2 +/- 5.4 mL/min/kg [p <0.0001]). The 6-minute walk test, which reflects the systemic response at the submaximal level of functional capacity, showed that the walking distance gradually and significantly increased for up to 1 year after endarterectomy (baseline, 358 +/- 102 meters [m]; at 1-month, 433 +/- 105 m; and at 1-year, 490 +/- 80 m [p < 0.0001]) and then reached a plateau. CONCLUSIONS After pulmonary endarterectomy, the hemodynamic recovery occurred immediately, and the patients' exercise capacity improved during the year. The 6-minute walk test was a good indicator to assess the recovery of exercise capacity.
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Affiliation(s)
- Hitoshi Matsuda
- Department of Cardio-Vascular Surgery, National Cardio-Vascular Center, Suita, Osaka, Japan.
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12
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Auger WR, Kerr KM, Kim NHS, Ben-Yehuda O, Knowlton KU, Fedullo PF. Chronic thromboembolic pulmonary hypertension. Cardiol Clin 2004; 22:453-66, vii. [PMID: 15302364 DOI: 10.1016/j.ccl.2004.04.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
During the past 2 decades, there has been a steady rise in the number of patients with chronic thromboembolic pulmonary hypertension (CTEPH) undergoing surgery and in the number of programs worldwide dedicated to the diagnosis and management of this patient population. This article discusses the natural history and clinical presentation of CTEPH, the evaluation of patients for pulmonary thromboendarterectomy, and the outcomes following surgery, along with a brief review of the procedure as performed at the University of California, San Diego.
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Affiliation(s)
- William R Auger
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, 9300 Campus Point Drive, La Jolla, CA 92037, USA.
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13
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Klepetko W, Mayer E, Sandoval J, Trulock EP, Vachiery JL, Dartevelle P, Pepke-Zaba J, Jamieson SW, Lang I, Corris P. Interventional and surgical modalities of treatment for pulmonary arterial hypertension. J Am Coll Cardiol 2004; 43:73S-80S. [PMID: 15194182 DOI: 10.1016/j.jacc.2004.02.039] [Citation(s) in RCA: 153] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2003] [Accepted: 02/03/2004] [Indexed: 12/16/2022]
Abstract
Beyond medical therapy, different interventional and surgical approaches exist for treatment of pulmonary arterial hypertension (PAH). Atrial septostomy has been applied in patients with lack of response to medical therapy in the absence of other surgical treatment options. With growing experience, procedure-related death rates have been reduced to 5.4%, and the most suitable patient group has been identified among patients with a mean right atrial pressure between 10 and 20 mm Hg. Pulmonary endarterectomy is the accepted form of treatment for patients with chronic thromboembolic pulmonary hypertension. Establishing the diagnosis and the classification of the type of lesions by pulmonary angiography is crucial for optimal patient selection. Perioperative mortality rates have been reduced to <10% in experienced centers, and the hemodynamic improvement is dramatic and sustained. Lung and heart-lung transplantation remains the procedure of choice for patients unsuitable for other treatment modalities. Timing of the procedure is difficult because waiting times vary between centers and usually are in a high range. Early referral of patients unresponsive to other treatment forms is therefore of importance to avoid transplantation of patients with established significant comorbidity. The survival rate during the first five years after transplantation for PAH is intermediate among the lung diseases, lower than chronic obstructive pulmonary disease but higher than idiopathic pulmonary fibrosis.
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Affiliation(s)
- Walter Klepetko
- Department of Cardio-Thoracic Surgery, Vienna University Hospital, Vienna, Austria.
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14
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) should be differentiated from other etiologies of pulmonary hypertension since surgical intervention may be potentially curative. The presentation of this illness is nonspecific and may mimic other cardiopulmonary disease states. Without treatment, progressive pulmonary hypertension, right heart failure, and death will ensue. Echocardiography, lung ventilation-perfusion scan, right heart catheterization, and angiography are required for proper diagnosis and preoperative assessment. Definitive treatment requires surgical resection of thromboembolic material. The role of medical therapy remains to be defined.
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Affiliation(s)
- Timothy L Williamson
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, La Jolla 92037, USA
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15
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Ando M, Okita Y, Tagusari O, Kitamura S, Nakanishi N, Kyotani S. Surgical treatment for chronic thromboembolic pulmonary hypertension under profound hypothermia and circulatory arrest in 24 patients. J Card Surg 1999; 14:377-85. [PMID: 10875595 DOI: 10.1111/j.1540-8191.1999.tb01014.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious disease that induces hypoxemia and pulmonary hypertension, eventually leading to respiratory failure and right heart failure. We evaluated the results of surgical treatment in patients undergoing circulatory arrest under profound hypothermia. METHODS Between February 1995 and June 1999, 24 cases of CTEPH were surgically treated. The age of patients (11 males and 13 females) ranged from 21 to 71 years (mean 49+/-15 years). Because of hypoxemia, severe pulmonary hypertension (mean pulmonary artery pressure 45+/-7 mmHg ), and low cardiac output, the functional class of these patients was New York Heart Association (NYHA) III or IV. Following a median sternotomy, profound hypothermia was induced using cardiopulmonary bypass, and pulmonary thromboendarterectomy in the bilateral pulmonary arteries was performed under intermittent circulatory arrest. Surgery was performed emergently in four patients. RESULTS Of these 24 patients, 2 of 20 patients who underwent elective surgery and 3 of 4 patients who underwent emergent surgery died in the hospital. Symptoms of CTEPH markedly improved in 18 patients who survived the surgery. Pulmonary arterial pressure was decreased to 16+/-6 mmHg, and cardiac output was increased. CONCLUSIONS When CTEPH is resistant to medical treatment, surgical treatment is useful. When surgical indications are carefully selected, pulmonary thromboendarterectomy using intermittent circulatory arrest under profound hypothermia is quite effective for treating CTEPH.
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Affiliation(s)
- M Ando
- Department of Cardiovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan
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16
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Mayer E, Kramm T, Dalun M, Guth S, Oelert H. Surgical treatment of chronic thromboembolic pulmonary hypertension. Eur Surg 1999. [DOI: 10.1007/bf02619931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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17
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Kramm T, Mayer E, Dahm M, Guth S, Menzel T, Pitton M, Oelert H. Long-term results after thromboendarterectomy for chronic pulmonary embolism. Eur J Cardiothorac Surg 1999; 15:579-83; discussion 583-4. [PMID: 10386400 DOI: 10.1016/s1010-7940(99)00076-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE In patients with chronic thromboembolic pulmonary hypertension, pulmonary vascular resistance (PVR) can be reduced by pulmonary thromboendarterectomy (PTE). In this study, long-term symptomatic and hemodynamic effects were investigated. METHODS Twenty-two patients (12 female, 10 male, mean age 40 years, preoperative NYHA functional class II/III/IV: n = 1/12/9) were re-evaluated 48-72 months (mean 60 months) after surgery. In addition to clinical assessment, radiologic, hemodynamic and echocardiographic investigations were performed. RESULTS All patients reported a marked improvement of their clinical condition. At follow-up, 11 patients were identified as NYHA class I, 10 as NYHA class II and one patient was in class III. PVR and mean pulmonary artery pressure (mPAP) were significantly reduced (preoperative PVR 800+/-274 dynes/s per cm(-5), follow-up PVR 180+/-28.3 dynes/s per cm(-5); P < 0.001; preoperative mPAP 48.5+/-7.4 mmHg, follow-up mPAP 27.5+/-4.9 mmHg; P < 0.001). There was also a significant increase in arterial blood oxygen tension (preoperative PaO2 59+/-10 mmHg; follow-up PaO2 84+/-12 mmHg; P < 0.001). Chest roentgenograms and echocardiographic examinations revealed significantly decreased right heart dimensions and a recovery of right heart function. CONCLUSION In patients with severe chronic thromboembolic pulmonary hypertension, persistent symptomatic and hemodynamic improvements can be achieved by PTE.
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Affiliation(s)
- T Kramm
- Department of Cardiothoracic- and Vascular Surgery, Johannes Gutenberg University Hospital, Mainz, Germany.
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18
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Daily PO, Auger WR. Historical perspective: surgery for chronic thromboembolic disease. Semin Thorac Cardiovasc Surg 1999; 11:143-51. [PMID: 10378858 DOI: 10.1016/s1043-0679(99)70007-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Obstruction of major pulmonary vessels with organized thromboemboli is a rare sequelae of acute pulmonary embolic disease. Depending on the extent and duration of vascular occlusion, patients experiencing this unusual disorder may develop significant pulmonary hypertension and cor pulmonale. If left untreated, the ultimate clinical outcome is right heart failure and death. Over the past several decades, the description of this clinical entity has evolved from an autopsy curiosity to a recognized cause of chronic pulmonary hypertension. Also, during this same time period, surgical capabilities have greatly advanced, providing these patients a potentially life-saving remedy for this debilitating form of pulmonary vascular disease. This article provides a historical perspective for our current understanding of major vessel chronic thromboembolic pulmonary hypertension as a distinct clinical disorder. It also chronicles the developments in surgical techniques that have made thromboendarterectomy of the pulmonary arterial bed a reality.
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Affiliation(s)
- P O Daily
- Division of Cardiac Surgery, Sharp Memorial Hospital, San Diego, CA, USA
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19
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Daily PO, Dembitsky WP, Jamieson SW. The evolution and the current state of the art of pulmonary thromboendarterectomy. Semin Thorac Cardiovasc Surg 1999; 11:152-63. [PMID: 10378859 DOI: 10.1016/s1043-0679(99)70008-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Optimal reduction in pulmonary vascular resistance caused by chronic pulmonary embolism is obtained by bilateral pulmonary thromboendarterectomy with removal of occlusive material in all bronchopulmonary segmental arteries that are partially or completely obstructed. The most effective way to obtain this goal is the use of median sternotomy with cardiopulmonary bypass, deep hypothermia, and intermittent periods of circulatory arrest. During circulatory arrest, thromboendarterectomy is performed by specially designed dissectors that allow simultaneous dissection and removal of blood from the surgical field. The operative mortality rate for pulmonary thromboendarterectomy at the University of California, San Diego, between 1990 and 1998 was 9.2% in 1,049 patients.
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Affiliation(s)
- P O Daily
- Division of Cardiac Surgery, Sharp Memorial Hospital, San Diego, CA, USA
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Ando M, Takamoto S, Okita Y, Matsukawa R, Nakanishi N, Kyotani S, Satoh T. Operation for chronic pulmonary thromboembolism accompanied by thrombophilia in 8 patients. Ann Thorac Surg 1998; 66:1919-24. [PMID: 9930469 DOI: 10.1016/s0003-4975(98)00910-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Medical therapy for chronic pulmonary thromboembolism is limited, and surgical treatment has become more frequent recently. We have performed pulmonary thromboendarterectomy on 8 patients with chronic pulmonary thromboembolism accompanied by thrombophilia. METHODS The patients were 6 men and 2 women aged 21 to 56 years (mean, 35 years). Five patients had antiphospholipid syndrome, 2 had protein C deficiency, and 1 had congenital antithrombin III deficiency. The preoperative condition was New York Heart Association functional class III in 5 and class IV in 3. Hypoxemia, marked pulmonary hypertension (mean pulmonary artery pressure, 47+/-6.7 mm Hg), and low cardiac output were observed in all patients. After a median sternotomy, deep hypothermia was induced using a cardiopulmonary bypass, and pulmonary thromboendarterectomy in the bilateral pulmonary arteries was performed under intermittent circulatory arrest. RESULTS There were no operative deaths. Long-term respiratory management was needed postoperatively by 3 patients. In the remaining 5 patients, no reperfusion injury was observed. The arterial blood oxygen concentration improved, and the mean pulmonary pressure decreased to 16+/-5.5 mm Hg. The cardiac output also increased, and New York Heart Association functional class improved to I in 4 and II in 4 patients. CONCLUSION Pulmonary thromboendarterectomy under deep hypothermic intermittent circulatory arrest was effective for chronic pulmonary thromboembolism accompanied by thrombophilia for which medical treatment is of limited value.
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Affiliation(s)
- M Ando
- Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Suita, Japan
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21
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Ando M, Okita Y, Matsukawa R, Kitamura S. Chronic pulmonary thromboendarterectomy complicated by antithrombin III deficiency and antiphospholipid syndrome. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 1998; 46:1082-7. [PMID: 9884556 DOI: 10.1007/bf03217880] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pulmonary thromboendarterectomy was performed on two patients with chronic pulmonary thromboembolism showing thrombotic tendency. Patient 1 was a 25-year-old male with the disease complicated by congenital antithrombin III deficiency. Patient 2 was a 21-year-old male with the disease complicated by antiphospholipid syndrome. Both patients were admitted to the center upon showing dyspnea. Lung perfusion scintigraphy revealed multiple defects in the right and left lungs. Pulmonary arteriography showed occlusion and stenosis from lobar to segmental arteries. Cardiac catheterization showed marked pulmonary hypertension. Pulmonary angioscopy confirmed the presence of organized thrombi while an intravascular ultrasound revealed a thickening of the pulmonary arterial walls in both lungs. After the insertion of an inferior vena cava filter in each patient, surgery was performed. Following a median sternotomy, a cardiopulmonary bypass was utilized to induce deep hypothermia at a pharyngeal temperature of 16 degrees C, after which a thromboendarterectomy of the bilateral pulmonary arteries was performed under intermittent circulatory arrest. A large amount of organized thrombi was extracted from these arteries. After surgery, both patients showed good postoperative outcome with improved blood flow in both lungs, reduced pulmonary arterial pressure and increased cardiac output.
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Affiliation(s)
- M Ando
- Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan
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Mayer E, Dahm M, Hake U, Schmid FX, Pitton M, Kupferwasser I, Iversen S, Oelert H. Mid-term results of pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension. Ann Thorac Surg 1996; 61:1788-92. [PMID: 8651785 DOI: 10.1016/0003-4975(96)00169-5] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In patients with chronic thromboembolic pulmonary hypertension, acute and striking decreases of pulmonary artery pressures and vascular resistance can be achieved by pulmonary thromboendarterectomy. In this study, the long-term effects of pulmonary thromboendarterectomy on hemodynamic indices and right ventricular function were investigated. METHODS Sixty-five patients (31 women and 34 men; mean age, 47 +/- 17 years; range, 19 to 69 years; New York Heart Association [NYHA] functional class II, n = 3; class III, n = 38; class IV, n = 24) were reassessed 13 to 48 months (mean, 27 months) after pulmonary thromboendarterectomy. Measurements are reported as mean +/- standard deviation. RESULTS All patients reported a significant improvement of symptoms: 46 patients were in NYHA functional class I, 16 patients in class II, and 3 patients in class III. Mean pulmonary vascular resistance was significantly reduced compared with preoperative and postoperative values (preoperative: 1,015 +/- 454 dynes.s.cm-5; postoperative: 322 +/- 154 dynes.s.cm-5; follow-up: 198 +/- 72 dynes.s.cm-5; p < 0.001 versus preoperative; p < 0.025 versus postoperative). Concomitantly, cardiac index was significantly increased compared with preoperative values (preoperative: 2.0 +/- 0.7 L.min-1.m-2; follow-up: 2.9 +/- 0.5 L.min-1.m-2; p < 0.001). Significant reductions of right ventricular dimensions and recovery of right ventricular function could be demonstrated radiologically and echocardiographically. In 3 patients (preoperative NYHA class IV, NYHA class III at follow-up) with proven coagulation abnormalities, pulmonary vascular resistance was moderately increased at follow-up compared with postoperative measurements. CONCLUSIONS In patients with chronic thromboembolic pulmonary hypertension, a persistent decrease of pulmonary vascular resistance and improvement of right ventricular function and NYHA functional status can be achieved by pulmonary thromboendarterectomy.
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Affiliation(s)
- E Mayer
- Department for Cardiothoracic, Johannes Gutenberg-University Hospital Mainz, Germany
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23
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24
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Tscheliessnigg KH. Eingeladener Kommentar: Pulmonale Thrombendarterektomie—eine neue Methode? Eur Surg 1995. [DOI: 10.1007/bf02602276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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25
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Kauczor HU, Schwickert HC, Mayer E, Kersjes W, Moll R, Schweden F. Pulmonary artery sarcoma mimicking chronic thromboembolic disease: computed tomography and magnetic resonance imaging findings. Cardiovasc Intervent Radiol 1994; 17:185-9. [PMID: 7954571 DOI: 10.1007/bf00571532] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE The diagnosis of the rare primary malignant tumors of the pulmonary arteries is often delayed as symptoms are nonspecific. METHODS Computed tomography (CT) and magnetic resonance imaging (MRI) of three patients with occlusion of the right pulmonary artery, two with sarcoma and one with chronic thromboembolic disease were analyzed for discriminating diagnostic criteria. RESULTS Criteria suggesting pulmonary artery sarcoma are inhomogeneous high or low attenuation (hemorrhage, necrosis), soft-tissue density in pulmonary arteries, vascular distension, enhancement after administration of gadopentetate dimeglumine. Criteria for chronic thromboembolic disease are homogeneous soft-tissue lesions, abrupt vascular narrowings and cut-offs, as well as regional parenchymal hyperdensities. CONCLUSION CT and MRI provide complementary findings suggesting advanced pulmonary artery sarcoma instead of chronic thromboembolism.
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Affiliation(s)
- H U Kauczor
- Klinik mit Poliklinik für Radiologie, Universität Mainz, Germany
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Daily PO. Invited letter concerning: Myocardial temperature management during aortic clamping for cardiac surgery: protection, preoccupation, and perspective (J Thorac Cardiovasc Surg 1991;102:895-903). J Thorac Cardiovasc Surg 1993. [DOI: 10.1016/s0022-5223(19)33720-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Nakagawa Y, Masuda M, Shiihara H, Tsuruta Y, Abe H, Miura M, Tanaka H. Successful pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension associated with anticardiolipin antibodies: report of a case. Surg Today 1992; 22:548-52. [PMID: 1472796 DOI: 10.1007/bf00308902] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Chronic pulmonary thromboembolism with pulmonary hypertension is a rare but most unique syndrome in the broad spectrum of pulmonary embolism. This report describes a successful pulmonary thromboendarterectomy performed for a totally occluded right pulmonary artery on a 43 year old man who presented with positive cardiolipin antibodies. The surgery was performed through a median sternotomy with cardiopulmonary bypass and intermittent periods of deep hypothermic circulatory arrest. We are convinced that this method allows for complete removal of the thrombotic obstruction and should be the procedure of choice for patients with very proximal obstruction of a pulmonary artery.
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Affiliation(s)
- Y Nakagawa
- First Department of Surgery, Chiba University School of Medicine, Japan
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Abstract
Even with circulatory arrest during pulmonary thromboendarterectomy, continued back-bleeding obscures the operative field. This necessitates frequent interruptions of dissection to allow aspiration with a second instrument. Therefore, pulmonary thromboendarterectomy dissectors are described that allow simultaneous suction of blood from the operative field. Before the use of these dissectors, circulatory arrest time was 59 +/- 23 minutes in 124 consecutive patients. In the last 10 consecutive patients using these dissectors, the mean circulatory arrest time has been 52 +/- 22 minutes (p = not significant). It is anticipated that with a larger database, the ability to aspirate blood simultaneously during the dissecting process will result in a significant shortening of circulatory arrest time.
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Affiliation(s)
- P O Daily
- Sharp Memorial Hospital, San Diego, California
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30
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Ando M, Okita Y, Tagusari O, Kitamura S, Nakanishi N, Kyotani S. Surgical Treatment for Chronic Thromboembolic Pulmonary Hypertension Under Profound Hypothermia and Circulatory Arrest in 24 Patients. Echocardiography 1985. [DOI: 10.1111/j.1540-8175.1985.tb01311.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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