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Fujii S, Nagayoshi S, Matsumoto T, Miyamoto T, Ogawa K, Yoshimura M. Spontaneous hemodynamic improvement after balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension is observed within a short term after balloon pulmonary angioplasty. Cardiovasc Interv Ther 2024; 39:302-313. [PMID: 38329575 DOI: 10.1007/s12928-024-00987-6] [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: 11/10/2023] [Accepted: 01/06/2024] [Indexed: 02/09/2024]
Abstract
Natural hemodynamic changes after balloon pulmonary artery angioplasty (BPA) in a unified state without oxygen administration in patients with chronic thromboembolic pulmonary hypertension (CTEPH) remains undetermined. This study aimed to clarify the delayed changes in the hemodynamics after BPA in patients with CTEPH. We analyzed 73 consecutive patients with CTEPH who underwent BPA between July 2014 and December 2022. We extracted and evaluated hemodynamic data of the right heart catheter without oxygen administration immediately before and after the first BPA; and immediately before the second BPA, as the "post-delayed changes" after BPA. BPA significantly improved the mean pulmonary artery pressure (mPAP, mmHg) and pulmonary vascular resistance (PVR, dyn-s/cm5) from 36 (32-43) mmHg and 449 (312-627) dyn-s/cm5 before the first BPA to 28 (23-32) mmHg and 275 (217-366) dyn-s/cm5 immediately after BPA, and further significantly improved the values to 23 (20-28) mmHg and 225 (175-301) dyn-s/cm5 post-delayed changes after BPA, respectively. Improvement observed on account of delayed changes was observed both with and without pulmonary hypertension drugs. The delayed changes were observed during a period of 5-180 days, which did not correlate with the changes in mPAP and PVR. Hemodynamic improvement owing to BPA was observed immediately after BPA; however, further improvement was observed as a result of delayed changes. mPAP improved by 3.4 ± 5.2 mmHg and PVR by 53 (10-99) dyn-s/cm5 as delayed improvement. mPAP and PVR showed delayed improved by approximately 10% of their values before BPA.
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Affiliation(s)
- Shinya Fujii
- Division of Cardiology, Saitama Cardiovascular and Respiratory Center, 1696 Itai, Kumagaya City, Saitama, 360-0197, Japan.
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
| | - Shinya Nagayoshi
- Division of Cardiology, Saitama Cardiovascular and Respiratory Center, 1696 Itai, Kumagaya City, Saitama, 360-0197, Japan
| | - Takuya Matsumoto
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Miyamoto
- Division of Cardiology, Saitama Cardiovascular and Respiratory Center, 1696 Itai, Kumagaya City, Saitama, 360-0197, Japan
| | - Kazuo Ogawa
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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Kanezawa M, Shimokawahara H, Ejiri K, Goten C, Okada H, Sato K, Yuasa S, Matsubara H. Effects of medical therapy and age on cardiac output changes following balloon pulmonary angioplasty: Implications for combination therapy in chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2024:S1053-2498(24)01661-9. [PMID: 38759765 DOI: 10.1016/j.healun.2024.05.007] [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: 02/06/2024] [Revised: 05/01/2024] [Accepted: 05/06/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Some patients with chronic thromboembolic pulmonary hypertension (CTEPH) exhibit exercise intolerance due to reduced cardiac output (CO) even after successful balloon pulmonary angioplasty (BPA). Medical therapy is a potential option for such cases; however, it is unclear which patients necessitate it even after BPA. METHODS This study included 286 patients with CTEPH who underwent BPA and right heart catheterization 1 year after the final BPA and classified them into no-medication and withdrawal groups. The no-medication group comprised patients without pulmonary hypertension (PH) medications before and after BPA, while the withdrawal group included patients who received PH medications before BPA and discontinued them after BPA. We assessed differences in the changes in CO after BPA from baseline (ΔCO) between the 2 groups. Additionally, we evaluated the ΔCO among different age categories within each group: younger (<60 years), middle-aged (60-70 years), and older adults (≥70 years). RESULTS After adjusting baseline covariates, overall CO did not differ significantly. However, ΔCO was significantly positive in the no-medication group but negative in the withdrawal group (0.32 and -0.33, difference in ΔCO: -0.65, 95% confidence intervals: -0.90 to -0.40). A significantly positive effect on ΔCO was observed in younger and middle-aged individuals, with a significant interaction between age and ΔCO in no-medication groups. CONCLUSIONS Increasing CO with BPA alone may be challenging with age in patients with CTEPH. Given that discontinuation of PH medication after BPA decreased CO more than the effect of BPA, medical therapy might be necessary even after successful BPA.
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Affiliation(s)
- Misaki Kanezawa
- Department of Cardiology, NHO Okayama Medical Center, Okayama, Japan; Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | | | - Kentaro Ejiri
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Chiaki Goten
- Department of Cardiology, NHO Okayama Medical Center, Okayama, Japan
| | - Hirofumi Okada
- Department of Cardiology, NHO Okayama Medical Center, Okayama, Japan
| | - Kimi Sato
- Department of Cardiology, NHO Okayama Medical Center, Okayama, Japan
| | - Shinsuke Yuasa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiromi Matsubara
- Department of Cardiology, NHO Okayama Medical Center, Okayama, Japan
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Suruga K, Shimokawahara H, Miyagi A, Sugiyama Y, Suetomi T, Ogawa A, Matsubara H. Flow Grade-Based Success Rates, Complication Rates, and Balloon Pulmonary Angioplasty Patency for Total Occlusions. Can J Cardiol 2024; 40:625-633. [PMID: 38081510 DOI: 10.1016/j.cjca.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND The number of successfully recanalized total occlusions affects hemodynamic improvement after balloon pulmonary angioplasty (BPA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to clarify the current efficacy, patency, and success rate of BPA for total occlusions. METHODS Between April 2016 and August 2021, 178 BPAs were performed in 100 patients with CTEPH and total occlusions. The primary success and subsequent patency rates immediately before the second BPA procedure (follow-up) were compared between the segmental and subsegmental groups, based on the flow grade, which was defined as follows: 0, no reperfusion; 1, minimal reperfusion; 2, partial reperfusion; and 3, complete reperfusion. RESULTS Total occlusions were mainly located in the right lung (70%) and lower lobes (48%). The primary success rate was 88%, with significant improvements in oxygenation, hemodynamic parameters, and 6-minute walk test. The primary flow grade did not differ between groups. However, the proportion of lesions with a flow grade of 2 or 3 at follow-up was significantly higher in the subsegmental group than in the segmental group (84% vs 45%, respectively; P < 0.01). In multivariate analysis, flow grade in the acute phase (odds ratio [OR], 46.9; 95% confidence interval [CI], 12.54-176.78; P < 0.01) and subsegmental lesions (OR, 13.8; 95% CI, 3.24-58.94; P < 0.01) were independently associated with better patency (flow grade of 2 or 3) at follow-up. CONCLUSIONS Total occlusions can be safely and effectively treated with BPA. BPA for total occlusions may be preferable for subsegmental over segmental lesions.
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Affiliation(s)
- Kazuki Suruga
- Department of Cardiology and Clinical Science, NHO Okayama Medical Center, Okayama, Japan
| | - Hiroto Shimokawahara
- Department of Cardiology and Clinical Science, NHO Okayama Medical Center, Okayama, Japan.
| | - Ayane Miyagi
- Department of Cardiology and Clinical Science, NHO Okayama Medical Center, Okayama, Japan
| | - Yoichi Sugiyama
- Department of Cardiology and Clinical Science, NHO Okayama Medical Center, Okayama, Japan
| | - Takeshi Suetomi
- Department of Cardiology and Clinical Science, NHO Okayama Medical Center, Okayama, Japan
| | - Aiko Ogawa
- Department of Cardiology and Clinical Science, NHO Okayama Medical Center, Okayama, Japan
| | - Hiromi Matsubara
- Department of Cardiology and Clinical Science, NHO Okayama Medical Center, Okayama, Japan
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4
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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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Lang IM, Andreassen AK, Andersen A, Bouvaist H, Coghlan G, Escribano-Subias P, Jansa P, Kopec G, Kurzyna M, Matsubara H, Meyer BC, Palazzini M, Post MC, Pruszczyk P, Räber L, Roik M, Rosenkranz S, Wiedenroth CB, Redlin-Werle C, Brenot P. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: a clinical consensus statement of the ESC working group on pulmonary circulation and right ventricular function. Eur Heart J 2023:ehad413. [PMID: 37470202 PMCID: PMC10393078 DOI: 10.1093/eurheartj/ehad413] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/08/2023] [Accepted: 06/12/2023] [Indexed: 07/21/2023] Open
Abstract
The current treatment algorithm for chronic thromboembolic pulmonary hypertension (CTEPH) as depicted in the 2022 European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines on the diagnosis and treatment of pulmonary hypertension (PH) includes a multimodal approach of combinations of pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA) and medical therapies to target major vessel pulmonary vascular lesions, and microvasculopathy. Today, BPA of >1700 patients has been reported in the literature from centers in Asia, the US, and also Europe; many more patients have been treated outside literature reports. As BPA becomes part of routine care of patients with CTEPH, benchmarks for safe and effective care delivery become increasingly important. In light of this development, the ESC Working Group on Pulmonary Circulation and Right Ventricular Function has decided to publish a document that helps standardize BPA to meet the need of uniformity in patient selection, procedural planning, technical approach, materials and devices, treatment goals, complications including their management, and patient follow-up, thus complementing the guidelines. Delphi methodology was utilized for statements that were not evidence based. First, an anatomical nomenclature and a description of vascular lesions are provided. Second, treatment goals and definitions of complete BPA are outlined. Third, definitions of complications are presented which may be the basis for a standardized reporting in studies involving BPA. The document is intended to serve as a companion to the official ESC/ERS guidelines.
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Affiliation(s)
- Irene M Lang
- Department of Internal Medicine II, Cardiology, and Comprehensive Center of Cardiovascular Medicine CCVM, Medical University of Vienna, Währinger Gürtel 18-20, Vienna A-1090, Austria
| | - Arne K Andreassen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Pb 4950 Nydalen, 0424 Oslo, Norway
| | - Asger Andersen
- Aarhus University Hospital, Palle Juul Jensens Boulevard 99 8200 Aarhus N Denmark
| | - Helene Bouvaist
- Cardiology Department, Grenoble - Alpes University Hospital, 38043 Grenoble, France
| | - Gerry Coghlan
- Royal Free Hospital, London, Pond Street, Middlesex, London, NW3 2QG
| | | | - Pavel Jansa
- General University Hospital, U Nemocnice 2, 128 08 Prague 2, Czech Republic
| | - Grzegorz Kopec
- Pulmonary Circulation Centre Jagiellonian University Medical College, John Paul II Hospital in Krakow, Pradnicka Str. 80, 31-202 Krakow
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology Centre of Postgraduate Medical Education, EHC Otwock, Borowa 14/18, Otwock 05-400, Poland
| | - Hiromi Matsubara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan
| | - Bernhard Christian Meyer
- Medizinische Hochschule Hannover - Institut für Diagnostische und Interventionelle Radiologie Carl-Neuberg-Str. 1, 30625 Hannover
| | - Massimiliano Palazzini
- Dipartimento DIMEC (Dipartimento di Scienze Mediche e Chirurgiche), Università di Bologna, 40126 Bologna, Italy
| | - Marco C Post
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Zwirki I Wigury 61, 02-091 Warsaw, Poland
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern Freiburgstrasse 18 3010 Bern, Switzerland
| | - Marek Roik
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Zwirki I Wigury 61, 02-091 Warsaw, Poland
| | - Stephan Rosenkranz
- Dept. of Cardiology and Cologne Cardiovascular Research Center, Heart Center at the University Hospital Cologne, Kerpener Str. 62, 50937 Köln, Germany
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Centre, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
| | - Carlo Redlin-Werle
- Department of Internal Medicine II, Cardiology, and Comprehensive Center of Cardiovascular Medicine CCVM, Medical University of Vienna, Währinger Gürtel 18-20, Vienna A-1090, Austria
| | - Philippe Brenot
- Interventional Radiology Department, Marie Lannelongue Hospital, Le Plessis Robinson 92350 France
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Tabuchi I, Ogawa A, Shigetoshi M, Shimokawahara H, Ito H, Matsubara H. Low incidence of restenosis after successful balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension. Cardiovasc Interv Ther 2023; 38:231-240. [PMID: 35733028 DOI: 10.1007/s12928-022-00866-y] [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: 11/07/2021] [Accepted: 05/30/2022] [Indexed: 11/02/2022]
Abstract
Balloon pulmonary angioplasty (BPA) is now a treatment option for patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). However, the incidence of restenosis and long-term changes in vessel diameters in pulmonary arteries after BPA are unknown. The present study investigated the incidence of restenosis by measuring changes in vessel diameter after BPA. We reviewed 58 patients (168 lesions) with CTEPH who underwent single dilation for the target lesion (type A/B/C lesions) during BPA procedure followed by selective pulmonary angiography more than 6 months after the final BPA procedure. The outcomes of BPA were assessed in terms of pulmonary artery diameters. In a median follow-up of 1.9 (1.2-2.7) years, restenosis occurred in only one case with a type C lesion after BPA (0.6%). In type A/B lesions, the minimal lumen diameter was significantly enlarged at follow-up after BPA [3.48 (2.59-4.34) to 4.22 (3.31-4.90) mm]. In type C lesions, the minimal lumen diameter was unchanged at follow-up after BPA [3.15 (1.96-3.64) to 3.28 (2.38-4.61) mm]. The present results revealed that restenosis after BPA rarely occurs in type A/B/C lesions. Minimal lumen diameters for type A/B lesions continually increased and those for type C lesions did not decrease. Stent implantation in type A/B/C lesions would be unnecessary after BPA.
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Affiliation(s)
- Isao Tabuchi
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama, 701-1192, Japan
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Aiko Ogawa
- Department of Clinical Science, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama, 701-1192, Japan
| | - Masataka Shigetoshi
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama, 701-1192, Japan
| | - Hiroto Shimokawahara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama, 701-1192, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Hiromi Matsubara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama, 701-1192, Japan.
- Department of Clinical Science, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama, 701-1192, Japan.
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7
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Nishihara T, Shimokawahara H, Ogawa A, Naito T, Une D, Mukai T, Niiya H, Ito H, Matsubara H. Comparison of the safety and efficacy of balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension patients with surgically accessible and inaccessible lesions. J Heart Lung Transplant 2023; 42:786-794. [PMID: 36792382 DOI: 10.1016/j.healun.2023.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 11/27/2022] [Accepted: 01/10/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Although pulmonary endarterectomy is the treatment of choice for chronic thromboembolic pulmonary hypertension, not all patients are eligible. While balloon pulmonary angioplasty is an alternative for such patients, its efficacy and safety may differ between patients with and without surgically accessible lesions. METHODS This study involved 344 patients treated with balloon pulmonary angioplasty who were ineligible for pulmonary endarterectomy. Based on the angiographical lesion location, patients were divided into the surgically accessible (Group 1) and inaccessible (Group 2) groups, and percent changes in hemodynamics and clinical parameters before and after balloon pulmonary angioplasty were investigated. We also conducted survival analyses using Kaplan-Meier analysis. RESULTS While no differences in baseline characteristics were identified between the groups, balloon pulmonary angioplasty significantly improved hemodynamics in both groups, without any difference regarding the incidence of complications. Meanwhile, the percent changes in the mean pulmonary arterial pressure, pulmonary vascular resistance, 6-min walk distance, right ventricular area index on echocardiography, and the achievement rate of World Health Organization functional class I after balloon pulmonary angioplasty were significantly lower in Group 1 than in Group 2. The cumulative survival rates at 1, 5, and 10 years after balloon pulmonary angioplasty were not significantly different between the two groups (Group 1: 92.5%, 86.1%, 84.3%; and Group 2: 96.5%, 92.9%, 90.1%, respectively). CONCLUSIONS The outcome of balloon pulmonary angioplasty in inoperable patients with surgically accessible proximal lesions was acceptable; however, further investigations are necessary to clarify the optimal treatment for such patients.
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Affiliation(s)
- Takahiro Nishihara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan; Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroto Shimokawahara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan.
| | - Aiko Ogawa
- Department of Clinical Science, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Takanori Naito
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Dai Une
- Department of Cardiovascular surgery, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Takashi Mukai
- Department of Radiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Harutaka Niiya
- Department of Radiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiromi Matsubara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
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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: 439] [Impact Index Per Article: 439.0] [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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Ejiri K, Ogawa A, Shimokawahara H, Matsubara H. Treatment of Vascular Injury During Balloon Pulmonary Angioplasty in Patients With Chronic Thromboembolic Pulmonary Hypertension. JACC. ASIA 2022; 2:831-842. [PMID: 36713759 PMCID: PMC9877217 DOI: 10.1016/j.jacasi.2022.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/01/2022] [Accepted: 08/14/2022] [Indexed: 12/03/2022]
Abstract
Background Treatment strategy for vascular injury during balloon pulmonary angioplasty (BPA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) was uncertain. Objectives This study aimed to identify an optimal therapeutic strategy for vascular injury during BPA in patients with CTEPH. Methods This study reviewed 207 patients with CTEPH and 956 BPA procedures between November 1, 2012 and November 30, 2015. Patients who were diagnosed with vascular injury during BPA, which was defined as angiographic signs or sudden respiratory and hemodynamic defects were included in this study. The study investigated the safety and efficacy of the hierarchically systematic treatment strategy including gelatin sponge embolization (GSE). Results More than one-half of the 79 patients and 133 procedures with vascular injury were improved by general treatment with reversal of heparin and high-flow oxygen administration. The investigators performed conventional treatment of proximal vessel occlusion using a guiding or balloon catheter in 47 procedures (35%) in which the culprit vessels could be detected under patients' stable conditions. In 32 procedures (24%) without detected culprit lesions or improvement by conventional treatment, GSE could significantly improve patient condition. The treatment strategy obtained successful bailout in 98% of procedures with vascular injury. No patients who underwent GSE died within 30 days after the treatment. There was no significant difference in cumulative mortality rate (median follow-up: 6.6 years) between groups with or without GSE (15.6% vs 8.2%; adjusted HR: 1.47; 95% CI: 0.25-8.69; P = 0.67). Conclusions Treatment strategy including GSE would be promising for vascular injury during BPA in patients with CTEPH.
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Affiliation(s)
- Kentaro Ejiri
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan,Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Aiko Ogawa
- Department of Clinical Science, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Hiroto Shimokawahara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Hiromi Matsubara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan,Department of Clinical Science, National Hospital Organization Okayama Medical Center, Okayama, Japan,Address for correspondence: Dr Hiromi Matsubara, Departments of Cardiology and Clinical Science, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama, Japan, 7011192.
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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: 1036] [Impact Index Per Article: 518.0] [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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Seo YJ, Shim DB, Sharif A, Samson Z, Takechi R, Brown D. Circulatory disturbance of the cochlear spiral modiolar artery in a type 2 diabetic mouse model. Laryngoscope Investig Otolaryngol 2022; 7:1568-1574. [PMID: 36258860 PMCID: PMC9575088 DOI: 10.1002/lio2.917] [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: 05/17/2022] [Revised: 07/26/2022] [Accepted: 08/24/2022] [Indexed: 11/18/2022] Open
Abstract
Objective This study aimed to identify significant differences in cochlea microvessel size between a diabetic mouse model (db/db) and normal mice using three‐dimensional (3D) quantitative analysis. Methods Six control heterozygote db/+ as well as 18 male B6/BKS(D)‐Leprdb/J (db/db) mice aged 14 (n = 9) and 28 (n = 9) weeks were examined. After clearing the cochlea, we reconstructed the 3D volumes of the spiral modiolar artery (SMA) in the cochlea using light‐sheet microscopy and analyzed vessel wall thickness, cross‐sectional area, short and long diameter, and vessel height. Results The average SMA‐wall thickness in the db/db‐mouse group (3.418 ± 0.328 μm) was greater than that in the control group (2.388 ± 0.411 μm). The average cross‐sectional outer area, short diameter, and long diameter of the SMA in db/db mice were significantly larger than those in control mice (all p < 0.001). The cross‐sectional areas increased with age (control: 221.782 ± 121.230 μm, 14 weeks; 294.378 ± 151.008 μm, and 28 weeks; 312.925 ± 147.943 μm). Conclusion The db/db mice had thicker and larger proximal‐SMA vessel walls and diameters than control mice, respectively, thus potentially inducing increased blood viscosity or vascular insufficiency and aggravating hearing loss in type 2 diabetes mellitus. Level of Evidence IIb
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Affiliation(s)
- Young Joon Seo
- Department of Otorhinolaryngology Yonsei University Wonju College of Medicine Wonju South Korea
- Research Institute of Hearing Enhancement, Yonsei University Wonju College of Medicine Wonju South Korea
- Faculty of Health sciences Curtin University Bentley WA Australia
| | - Dae Bo Shim
- Department of Otorhinolaryngology Myongji Hospital, Hanyang University College of Medicine
| | - Arazu Sharif
- Curtin Health Innovation Research Institute, Curtin University Bentley WA Australia
| | - Zeke Samson
- Faculty of Health sciences Curtin University Bentley WA Australia
| | - Ryu Takechi
- Curtin Health Innovation Research Institute, Curtin University Bentley WA Australia
| | - Daniel Brown
- Faculty of Health sciences Curtin University Bentley WA Australia
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12
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Update on balloon pulmonary angioplasty for treatment of chronic thromboembolic pulmonary hypertension. Curr Opin Pulm Med 2022; 28:369-374. [PMID: 35938199 DOI: 10.1097/mcp.0000000000000898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To provide an update on balloon pulmonary angioplasty (BPA) for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH), a pulmonary vascular disease that is characterized by fibro-thrombotic material mechanically obliterating major pulmonary arteries, resulting in increased pulmonary vascular resistance (PVR), progressive pulmonary hypertension (PH) combined with a microscopic pulmonary vasculopathy [1▪▪], right ventricular (RV) failure [2] and premature death. RECENT FINDINGS Data from a most recent CTEPH European registry (2015 and 2016) suggest significantly improved survival [3▪] of CTEPH patients compared with survival in the eighties [4], or with data from 2007 and 2009 [5]. Pulmonary endarterectomy (PEA) is still the gold-standard therapy for CTEPH [6,7]. However, only around two thirds of all CTEPH patients are amenable to surgery [3▪,5]. Patients not suitable for PEA and treated conservatively have a poor prognosis [8]. BPA may have a role for this particular group of patients. [9-11]. Currently, BPA programs are available in many countries, with excellent results at expert centers [12-15,16▪,17,18▪▪]. Based on recent data, BPA seems to have a greater impact on symptomatic and hemodynamic improvement than medical therapy with riociguat alone [15]. SUMMARY The evidence favoring BPA is growing, but there is still a lack of published controlled trials. In addition, treatment concepts including indication, technical performance, use of PH-targeted medication, and the concept of follow-up vary between centers. In addition, there is a significant learning curve impacting outcomes [13]. The data from the International BPA registry will provide answers for some of the open questions.
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Changes in Inflammatory Markers in Patients with Chronic Thromboembolic Pulmonary Hypertension Treated with Balloon Pulmonary Angioplasty. Cells 2022; 11:cells11091491. [PMID: 35563797 PMCID: PMC9102042 DOI: 10.3390/cells11091491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/28/2022] [Accepted: 04/19/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Inflammatory response and endothelial dysfunction contribute to the progression of chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to assess changes in biomarkers involved in those processes in inoperable CTEPH patients treated with balloon pulmonary angioplasty (BPA). Methods: We enrolled 20 patients with inoperable CTEPH qualified for BPA and a control group. Interleukin 6, 8, 10 (IL-6, IL-8, IL-10), monocyte chemoattractant protein-1 (MCP-1), and C-reactive protein (hsCRP) constituted the markers of systemic inflammation. Endothelin 1 (ET-1) served as a marker of endothelial dysfunction. Selected markers were assessed before the BPA treatment, 24 h after the first BPA, and six months after completion of the BPA treatment. Results: At baseline, the CTEPH patients had increased serum concentrations of IL-6, IL-8 and ET-1. Twenty-four hours after a BPA session, we observed an increase in concentrations of IL-6 (∆ = 3.67 (1.41; 7.16); p < 0.001), of IL-10 (∆ = 0.25 (0; 0.47); p = 0.003), of MCP-1 (∆ = 111 (60.1; 202.8); p = 0.002), and of hsCRP (∆ = 4.81 (3.46; 8.47); p < 0.001). Six months after completion of the BPA treatment, there was a decrease in concentrations of IL-6 (∆ = −1.61 (−3.11; −0.20); p = 0.03), of IL8 (∆ = −3.24 (−7.72; 0.82); p = 0.01), and of ET-1 (∆ = −0.47 (−0.96; 0.05); p = 0.005). Conclusions: Patients with inoperable CTEPH exhibit increased systemic inflammation and endothelial dysfunction, which improves after completion of the BPA treatment. A single BPA session evokes an acute inflammatory response.
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The effectiveness of scoring balloon angioplasty in the treatment of chronic thromboembolic pulmonary hypertension. PLoS One 2022; 17:e0263244. [PMID: 35113935 PMCID: PMC8812943 DOI: 10.1371/journal.pone.0263244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 01/17/2022] [Indexed: 12/02/2022] Open
Abstract
Background Balloon pulmonary angioplasty (BPA) is an effective treatment for inoperable chronic thromboembolic pulmonary hypertension (CTEPH). The purpose of this study is to evaluate the therapeutic effect and safety of the non-slip element percutaneous transluminal angioplasty (NSE PTA) scoring balloons in BPA. Methods 108 pulmonary artery branches in 14 CTEPH patients who underwent BPA using NSE PTA scoring balloon (the NSE PTA group) or plain balloon (the POBA group) and pressure gradient evaluation were analyzed. We compared the improvement of the pressure ratios after BPA (Δ Pressure ratio) of both groups. Results There was no significant difference in the Δ Pressure ratios of the two groups (0.241 ± 0.196 POBA, 0.259 ± 0.177 NSE PTA, p = 0.63). No complications occurred in the NSE PTA group, while 3 episodes of hemoptysis were seen in the POBA group. This, however, was not found to be significant (p = 0.27). In the cases where balloon-to-vessel ratio exceeded 1.0 (n = 35), multivariate analysis showed that the use of NSE PTA scoring balloon and pressure ratio before BPA were significantly correlated with Δ Pressure ratio (β coefficient: 0.047, 95% CI: 0.0016 to 0.093, p = 0.043 and β coefficient: −0.60, 95% CI: −0.78 to −0.42, p < 0.01, respectively). Conclusions Although NSE PTA scoring balloon was safe, there was no significant pressure gradient improvement with NSE PTA scoring balloon compared to conventional BPA. Nevertheless, the NSE PTA scoring balloon showed effective blood-flow improvement in the case of large balloon-to-vessel ratio.
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15
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Tzoumas A, Peppas S, Sagris M, Papanastasiou CA, Barakakis PA, Bakoyiannis C, Taleb A, Kokkinidis DG, Giannakoulas G. Advances in treatment of chronic thromboembolic pulmonary hypertension. Thromb Res 2022; 212:30-37. [DOI: 10.1016/j.thromres.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/20/2022] [Accepted: 02/02/2022] [Indexed: 01/29/2023]
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Interventional Management of Chronic Thromboembolic Pulmonary Hypertension. Cardiol Clin 2021; 40:103-114. [PMID: 34809911 DOI: 10.1016/j.ccl.2021.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Chronic thromboembolic pulmonary hypertension is a distinct form of pulmonary hypertension characterized by the nonresolution of thrombotic material in the pulmonary tree; whenever feasible and safe, first-line treatment should be pulmonary thromboendarterectomy. In patients who are not operative candidates, balloon pulmonary angioplasty (BPA) has emerged as an effective treatment modality that results in improvements in functional class, symptoms, hemodynamics, 6-minute walk distance, and right ventricular and pulmonary artery mechanics. Careful attention to procedural technique and rapid identification and treatment of complications are critical for a successful BPA program.
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17
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Shigetoshi M, Hatanaka K, Ogawa A, Tabuchi I, Shimokawahara H, Munemasa M, Ito H, Matsubara H. Oxygen inhalation can selectively dilate pulmonary arteries in patients with chronic thromboembolic pulmonary hypertension before balloon angioplasty. J Cardiol 2021; 79:265-269. [PMID: 34563438 DOI: 10.1016/j.jjcc.2021.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/22/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Pulmonary injury is a major complication of balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH). Lung injury after BPA can be exacerbated by a high mean pulmonary arterial pressure (PAP). Although oxygen inhalation is expected to lower mean PAP in patients with CTEPH, no relevant investigation has been conducted. METHODS Consecutive patients with CTEPH who underwent BPA were enrolled in this study. We evaluated the hemodynamics using right heart catheterization while breathing ambient air and with administration of 5 L/min oxygen for 10 min. RESULTS This study included 52 consecutive patients with CTEPH, of whom 23 (44%) were treated with specific pulmonary vasodilators. Exposure to oxygen was well tolerated. Oxygen administration significantly decreased mean PAP by 3.8 ± 3.2 mmHg (p<0.001) and pulmonary vascular resistance by 0.8 ± 1.8 Wood units (p<0.001). Moreover, the ratio of pulmonary vascular resistance to systemic vascular resistance was significantly reduced by 13.5% (p<0.001). Multivariate regression analysis identified baseline mean PAP (β = -0.427, p = 0.006) as the only significant predictor of decreased mean PAP under oxygen administration. No significant difference in oxygen effect on mean PAP was found between patients with and without vasodilators. CONCLUSIONS In patients with CTEPH, 5 L/min supplemental oxygen inhalation could decrease mean PAP significantly by selective pulmonary artery dilatation, regardless of the usage of vasodilators, and thus could be helpful to maximize the safety of BPA. CLINICAL TRIAL REGISTRATION UMIN Clinical Trials Registry (No.: UMIN000026882); URL: https://www.umin.ac.jp/ctr/index.htm.
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Affiliation(s)
- Masataka Shigetoshi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Kunihiko Hatanaka
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan
| | - Aiko Ogawa
- Department of Clinical Science, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Isao Tabuchi
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan
| | - Hiroto Shimokawahara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan
| | - Mitsuru Munemasa
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Hiromi Matsubara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan.
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Fujii S, Nagayoshi S, Ogawa K, Muto M, Tanaka TD, Minai K, Kawai M, Yoshimura M. A pilot cohort study assessing the feasibility of complete revascularization with balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. PLoS One 2021; 16:e0254770. [PMID: 34270602 PMCID: PMC8284645 DOI: 10.1371/journal.pone.0254770] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 07/03/2021] [Indexed: 11/25/2022] Open
Abstract
Balloon pulmonary angioplasty improves prognosis by alleviating pulmonary hypertension in patients with chronic thromboembolic pulmonary hypertension, even with incomplete revascularization. However, hypoxia or the requirement for pulmonary vasodilators often remain even after pulmonary hypertension relief. With this cohort study, we aimed to examine whether complete revascularization by additional balloon pulmonary angioplasty on residual lesions, even after pulmonary hypertension relief, could resolve hypoxia or the requirement for pulmonary vasodilators. During complete revascularization with balloon pulmonary angioplasty in 42 patients with chronic thromboembolic pulmonary hypertension, we investigated therapeutic effects at baseline (T1), pulmonary hypertension relief phase (T2), and at 6 months post-final balloon pulmonary angioplasty (T3). The pulmonary hypertension relief phase was defined as the first time that a mean pulmonary artery pressure ≤ 25 mmHg or pulmonary vascular resistance ≤ 240 dyn-s/cm5 was reached in right heart catheterization before balloon pulmonary angioplasty. The partial pressure of oxygen increased progressively over T1, T2, and T3 (59.2±8.5, 69.0±9.7, and 80.0±9.5 mmHg, respectively; P<0.001 T2 vs. T3). Minimum oxygen saturation levels during the 6-minute walk distance test were 87% (81‒89%), 88% (84‒92%), and 91% (89‒93.3%), respectively (P<0.001 T2 vs. T3), with gradual increase in the 6-minute walk distance (346±125 m, 404±90 m, 454±101 m, respectively; P<0.001 T2 vs. T3). The percentages of patients using pulmonary vasodilators (54.8%, 45.2%, 4.8%, respectively; P<0.001 T2 vs. T3) and requiring oxygen therapy (26%, 26%, 7%, respectively; P = 0.008 T2 vs. T3) decreased significantly without hemodynamic exacerbation or major complications. Despite the discontinuation of pulmonary vasodilators, mean pulmonary artery pressure improved (36.0 [31.0‒41.3], 21.4±4.2, 18.5±3.6 mmHg, respectively; P<0.001 T2 vs. T3). Complete revascularization with balloon pulmonary angioplasty beyond pulmonary hypertension relief benefits patients with chronic thromboembolic pulmonary hypertension; it may improve oxygenation and exercise capacity, and reduce the need for pulmonary vasodilators and oxygen therapy.
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Affiliation(s)
- Shinya Fujii
- Division of Cardiology, Saitama Cardiovascular Respiratory Center, Kumagaya, Saitama, Japan
- * E-mail:
| | - Shinya Nagayoshi
- Division of Cardiology, Saitama Cardiovascular Respiratory Center, Kumagaya, Saitama, Japan
| | - Kazuo Ogawa
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Makoto Muto
- Division of Cardiology, Saitama Cardiovascular Respiratory Center, Kumagaya, Saitama, Japan
| | - Toshikazu D. Tanaka
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kosuke Minai
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Makoto Kawai
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: advances in patient and lesion selection. Curr Opin Pulm Med 2021; 27:303-310. [PMID: 34224432 DOI: 10.1097/mcp.0000000000000797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW Balloon pulmonary angioplasty (BPA) has been performed worldwide for patients who are ineligible for pulmonary endarterectomy (PEA). However, the technical details of BPA have not been standardized, and no international consensus regarding patient and lesion selection for BPA has been reached. Evidence for the combination of BPA with PEA or medical therapy is also lacking. This review highlights recent progress in BPA in terms of patient and lesion selection and the current procedural approach for BPA, including combination treatment. RECENT FINDINGS The indications for BPA have expanded with recent reports describing the improved safety and efficacy of BPA. Because lesions are generally present in all segmental and subsegmental pulmonary arteries, it is recommended to treat all the lesions to achieve desirable hemodynamic improvement. Selective pulmonary angiography is the gold standard for lesion selection in modern BPA aimed at total revascularization. Despite the lack of randomized controlled studies, combination treatment with BPA may be well tolerated and effective. SUMMARY BPA, alone or in combination with PEA or medical therapy, may be a treatment option for patients who are not candidates for monotreatment of PEA. However, further investigation is required to standardize patient and lesion selection for BPA.
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Kumar G, Effoe VS, Kumar A, Verma I, Sachdeva R. Intravascular ultrasound-guided catheter-based aspiration thrombectomy in patients with acute submassive pulmonary embolism: A case series. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 36:138-143. [PMID: 34099409 DOI: 10.1016/j.carrev.2021.05.016] [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: 04/25/2021] [Revised: 05/15/2021] [Accepted: 05/17/2021] [Indexed: 11/26/2022]
Abstract
Contrast pulmonary angiography by hand injection or power injection is widely used during catheter-based therapies for acute submassive and massive pulmonary embolism (PE). Particularly, in patients with pre-existing chronic kidney disease, this approach may present a prognostic challenge owing to a double-contrast load, initially during computed tomographic pulmonary angiography (CTPA), and during percutaneous treatment. Intravascular ultrasound (IVUS) has been used as an adjunctive imaging modality in the percutaneous treatment of chronic thromboembolic pulmonary hypertension, and in coronary and peripheral vascular interventions. We report a series of cases illustrating the use of IVUS in the management of acute PE. All five patients presented with an acute submassive PE with evidence of right ventricular (RV) strain (RV/LV ratio ≥ 0.90). Body mass index and B-type natriuretic peptide ranged from 18 to 47 kgm/m2 and 56-932 pg/mL (ref. ≤ 78), respectively. Three of the five patients had renal impairment prior to the procedure (acute kidney injury, AKI, and chronic kidney injury, CKD). Post-catheter-directed pulmonary embolectomy there was a modest reduction in mean pulmonary artery pressure in all five patients (range: -4 mmHg to -9 mmHg). The first case serves as a proof of concept of IVUS use in acute PE. This case series demonstrates that an IVUS-only approach in the catheter-directed management of acute submassive PE is feasible and may be of particular importance in patients with pre-existing renal dysfunction.
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Affiliation(s)
- Gautam Kumar
- Division of Cardiology, Atlanta VA Medical Center, Decatur, GA, United States of America; Division of Cardiology, The Andreas Gruentzig Cardiovascular Center, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Valery S Effoe
- Division of Cardiology, Morehouse School of Medicine, Atlanta, GA, United States of America
| | - Arnav Kumar
- Division of Cardiology, The Andreas Gruentzig Cardiovascular Center, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Isha Verma
- Division of Cardiology, Morehouse School of Medicine, Atlanta, GA, United States of America
| | - Rajesh Sachdeva
- Division of Cardiology, Atlanta VA Medical Center, Decatur, GA, United States of America.
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Shimokawahara H, Nagayoshi S, Ogawa A, Matsubara H. Continual Improvement in Pressure Gradient at the Lesion After Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension. Can J Cardiol 2021; 37:1232-1239. [PMID: 33744368 DOI: 10.1016/j.cjca.2021.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 03/05/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Lung injury is a serious complication of balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH). Selecting a smaller balloon might minimize the occurrence of lung injury; however, it could also increase the risk of restenosis. METHODS We analyzed the first target lesions in the initial BPA procedure in 34 consecutive patients with CTEPH. We measured proximal pressure with a guiding catheter and distal pressure with a pressure wire. We retrospectively investigated pressure gradients at the lesions before and immediately after the initial dilation with a smaller balloon and before the second procedure. RESULTS The proximal pressure decreased, and the distal pressure increased immediately after the initial balloon dilation. The pressure gradient at the lesion diminished significantly by the second procedure (from 26.4 ± 10.7 to 18.2 ± 9.9 mm Hg, P < 0.001) without serious complications. The residual pressure gradient had further diminished (to 9.8 ± 6.5 mm Hg, P = 0.02) until the second procedure. The reduction in pressure gradient at the lesion from immediately after the initial balloon dilation to the second procedure was positively correlated with both the baseline mean pulmonary arterial pressure (r2 = 0.23, P = 0.004) and residual pressure gradient immediately after the initial balloon dilation (r2 = 0.58, P < 0.001). CONCLUSIONS The residual pressure gradient at the lesion diminished continually after dilation with a smaller balloon. This strategy could decrease pulmonary arterial pressure safely. It would be reasonable to dilate the lesions sequentially in 2 procedures.
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Affiliation(s)
- Hiroto Shimokawahara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Shinya Nagayoshi
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Aiko Ogawa
- Department of Clinical Science, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Hiromi Matsubara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan; Department of Clinical Science, National Hospital Organization Okayama Medical Center, Okayama, Japan.
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22
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Coghlan JG, Rothman AM, Hoole SP. Balloon Pulmonary Angioplasty: State of the Art. ACTA ACUST UNITED AC 2021; 16:e02. [PMID: 33664801 PMCID: PMC7903587 DOI: 10.15420/icr.2020.14] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/01/2020] [Indexed: 12/14/2022]
Abstract
Balloon pulmonary angioplasty (BPA) is a novel technique for the treatment of chronic thromboembolic pulmonary hypertension. While cardiologists need no introduction to the concept of balloon angioplasty, BPA has its own particular challenges. This article aims to provide the reader with an overview of BPA, starting with an introduction to chronic thromboembolic disease (CTED), the standard management of chronic thromboembolic pulmonary hypertension (CTEPH), technical challenges faced when performing BPA and the evidence base supporting its use. The second part of the article will focus on the future of BPA, in particular the areas where research is required to establish an evidence base to justify the role of BPA in CTEPH and CTED treatment.
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23
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Park TK, Lee SH, Choi KH, Lee JM, Yang JH, Song YB, Hahn J, Choi J, Gwon H, Lee SH, Choi S. Late Survival Benefit of Percutaneous Coronary Intervention Compared With Medical Therapy in Patients With Coronary Chronic Total Occlusion: A 10-Year Follow-Up Study. J Am Heart Assoc 2021; 10:e019022. [PMID: 33660515 PMCID: PMC8174228 DOI: 10.1161/jaha.120.019022] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background As an initial treatment strategy, percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO) did not show midterm survival benefits compared with optimal medical therapy (OMT). We sought to evaluate the benefit of PCI compared with OMT in patients with CTO over extended long‐term follow‐up. Methods and Results Between March 2003 and February 2012, 2024 patients with CTO were enrolled in a single‐center registry and followed for ≈10 years. We excluded patients with CTO who underwent coronary artery bypass graft (n=477) and classified patients into the CTO‐PCI group (n=883) or OMT group (n=664) according to initial treatment strategy. Patients with multivessel disease received PCI for obstructive non‐CTO lesions in both groups. In the CTO‐PCI group, 699 patients (79.2%) underwent successful revascularization. The CTO‐PCI group had a lower 10‐year rate of cardiac death (10.4% versus 22.3%; hazard ratio [HR], 0.44 [95% CI, 0.32–0.59]; P<0.001) than the OMT group. After propensity score matching analyses, the CTO‐PCI group had a lower 10‐year rate of cardiac death (13.6% versus 20.8%; HR, 0.64 [95% CI, 0.45–0.91]; P=0.01) than the OMT group. The relative reduction in cardiac death at 10 years was mainly driven by a relative reduction between 3 and 10 years (8.3% versus 16.6%; HR, 0.43 [95% CI, 0.27–0.71]; P<0.001) but not at 3 years (5.7% versus 5.0%; HR, 1.12 [95% CI, 0.63–2.00]; P=0.71). The beneficial effects of CTO‐PCI were consistent among subgroups. Conclusions As an initial treatment strategy, CTO‐PCI might reduce late cardiac death compared with OMT in patients with CTO. Extended follow‐up of randomized trials may confirm the findings of the present study.
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Affiliation(s)
- Taek Kyu Park
- Division of CardiologyDepartment of MedicineHeart Vascular and Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - Seung Hun Lee
- Division of CardiologyDepartment of MedicineHeart Vascular and Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - Ki Hong Choi
- Division of CardiologyDepartment of MedicineHeart Vascular and Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - Joo Myung Lee
- Division of CardiologyDepartment of MedicineHeart Vascular and Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - Jeong Hoon Yang
- Division of CardiologyDepartment of MedicineHeart Vascular and Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - Young Bin Song
- Division of CardiologyDepartment of MedicineHeart Vascular and Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - Joo‐Yong Hahn
- Division of CardiologyDepartment of MedicineHeart Vascular and Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - Jin‐Ho Choi
- Division of CardiologyDepartment of MedicineHeart Vascular and Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - Hyeon‐Cheol Gwon
- Division of CardiologyDepartment of MedicineHeart Vascular and Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - Sang Hoon Lee
- Division of CardiologyDepartment of MedicineHeart Vascular and Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - Seung‐Hyuk Choi
- Division of CardiologyDepartment of MedicineHeart Vascular and Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulRepublic of Korea
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24
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Jin Q, Zhao ZH, Luo Q, Zhao Q, Yan L, Zhang Y, Li X, Yang T, Zeng QX, Xiong CM, Liu ZH. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: State of the art. World J Clin Cases 2020; 8:2679-2702. [PMID: 32742980 PMCID: PMC7360712 DOI: 10.12998/wjcc.v8.i13.2679] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/28/2020] [Accepted: 06/10/2020] [Indexed: 02/05/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a complex chronic disease in which pulmonary artery stenosis or obstruction caused by organized thrombus can lead to increased pulmonary artery pressure and pulmonary vascular resistance, ultimately triggering progressive right heart failure and death. Currently, its exact mechanism is not fully understood. Pulmonary endarterectomy (PEA) has immediate effects with low perioperative mortality and satisfactory prognosis in experienced expert centers for CTEPH patients with proximal lesions. Nevertheless, 37% of patients are deemed unsuitable for PEA surgery due to comorbidities and other factors, and nearly half of the operated patients have residual or recurrent pulmonary hypertension. Riociguat is the only approved drug for CTEPH, although its effect is limited. Balloon pulmonary angioplasty (BPA) is a promising alternative treatment for patients with CTEPH. After more than 30 years of development and refinements, emerging evidence has confirmed its role in patients with inoperable CTEPH or residual/recurrent pulmonary hypertension, with acceptable complications and comparable long-term prognosis to PEA. This review summarizes the pathophysiology of CTEPH, BPA history and development, therapeutic principles, indications and contraindications, interventional procedures, imaging modalities, efficacy and prognosis, complications and management, bridging and hybrid therapies, ongoing clinical trials and future prospects.
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Affiliation(s)
- Qi Jin
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zhi-Hui Zhao
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Qin Luo
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Qing Zhao
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Lu Yan
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yi Zhang
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Xin Li
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Tao Yang
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Qi-Xian Zeng
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Chang-Ming Xiong
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zhi-Hong Liu
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
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25
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Virtual Histology to Evaluate Mechanisms of Pulmonary Artery Lumen Enlargement in Response to Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Hypertension. J Clin Med 2020; 9:jcm9061655. [PMID: 32492788 PMCID: PMC7355673 DOI: 10.3390/jcm9061655] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/16/2020] [Accepted: 05/26/2020] [Indexed: 11/29/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) results from an obstruction of pulmonary arteries (PAs) by organized thrombi. The stenosed PAs are targeted during balloon pulmonary angioplasty (BPA). We aimed to evaluate the mechanism of BPA in inoperable patients with CTEPH. We analyzed stenosed PAs with intravascular grey-scale ultrasound (IVUS) to determine the cross-sectional area (CSA) of arterial lumen and of organized thrombi. The composition of organized thrombi was assessed using virtual histology. We distinguished two mechanisms of BPA: Type A with dominant vessel stretching, and type B with dominant thrombus compression. PAs were assessed before (n = 159) and after (n = 98) BPA in 20 consecutive patients. Organized thrombi were composed of dark-green (57.1 (48.0–64.0)%), light-green (34.0 (21.4–46.4)%), red (6.4 (2.9–11.7)%;) and white (0.2 (0.0–0.9)%) components. The mechanism type depended on vessel diameter (OR = 1.09(1.01–1.17); p = 0.03). In type B mechanism, decrease in the amount of light-green component positively correlated with an increase in lumen area after BPA (r = 0.50; p = 0.001). The mechanism of BPA depends on the diameter of the vessel. Dilation of more proximal PAs depends mainly on stretching of the vessel wall while dilation of smaller PAs depends on compression of the organized thrombi. The composition of the organized thrombi contributes to the effect of BPA.
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Karyofyllis P, Demerouti E, Papadopoulou V, Voudris V, Matsubara H. Balloon Pulmonary Angioplasty as a Treatment in Chronic Thromboembolic Pulmonary Hypertension: Past, Present, and Future. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020; 22:7. [DOI: 10.1007/s11936-020-0807-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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27
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Pulmonary Artery Elastic Properties After Balloon Pulmonary Angioplasty in Patients With Inoperable Chronic Thromboembolic Pulmonary Hypertension. Can J Cardiol 2019; 35:422-429. [PMID: 30935632 DOI: 10.1016/j.cjca.2019.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/27/2019] [Accepted: 01/27/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND A significant proportion of the right ventricular afterload is determined by the elastic properties of the pulmonary artery (PA). We aimed to assess the effect of balloon pulmonary angioplasty (BPA) on PA elastic properties in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). METHODS We enrolled adult patients with CTEPH treated with BPA and controls without PH. Total PA compliance (CPa) was calculated as stroke volume/PA pulse pressure. PA distensibility (DC) and compliance (CC) coefficients were assessed by intravascular ultrasound to denote local elastic properties of the treated PA segments. RESULTS We performed 103 BPA sessions in 17 patients with CTEPH (5 men [29%], aged 66 [64 to 73] years) who were followed for 6 (5 to 7) months after the last BPA. The median time between BPA sessions was 39 (28 to 52) days. The CPa, CC, and DC were lower in patients with CTEPH than in controls without PH (n = 10). Complete BPA treatment led to increase of CPa from 1.02 (0.70 to 1.39) to 2.08 (1.49 to 2.39) mL/mm Hg (P < 0.001) at the 6-month follow up, and this increase was in proportion to a decrease in pulmonary vascular resistance (PVR) (R2 = 0.74; P = 0.001). CPa increased immediately after BPA session by 0.13 (-0.05; 0.33) mL/mm Hg (P = 0.001) and remained unchanged until the next BPA session. CC and DC exhibited no immediate change after catheter balloon inflation (Δ=0 [-0.03; 0.02] mm2/mm Hg, P = 0.52, and Δ = 0 [-0.13; 0.13] %/mm Hg, P = 0.91, respectively) and remained unchanged at the 6-month follow-up. CONCLUSIONS BPA improved total CPa in proportion to a decrease in PVR despite no improvement in local elastic properties of the treated PA segments.
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