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Smits AJ, Isebia K, Combee-Duffy C, van der Wal S, Nossent EJ, Boonstra A, Vonk-Noordegraaf A, Bogaard HJ, Serné EH. Low nailfold capillary density in patients with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension: biomarker of clinical outcome? Sci Rep 2024; 14:19467. [PMID: 39174569 PMCID: PMC11341751 DOI: 10.1038/s41598-024-69017-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: 04/05/2024] [Accepted: 07/30/2024] [Indexed: 08/24/2024] Open
Abstract
Nailfold capillary density is lower in patients with pulmonary arterial hypertension (PAH). It is unclear whether this observation signifies a unique systemic manifestation of PAH, or reflects microcirculatory dysfunction secondary to pulmonary hypertension (PH). Capillary density and loop dimensions were measured by nailfold-capillaroscopy (NC) in 30 PAH (23 idiopathic, or iPAH, 7 hereditary, or hPAH), 17 chronic thromboembolic PH (CTEPH) patients and 48 controls. NC-Measurements were repeated after pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA) in CTEPH patients. We examined whether NC-measurements were related to markers of disease severity and predictive of time to clinical worsening (TTCW) as tested by univariate linear/logistic regression and cox-regression analysis, respectively. Capillary density was significantly lower in PAH (7.5 ± 1.1, p < 0.001) and in CTEPH (8.4 ± 1.5, p < 0.001) compared to asymptomatic controls (10.3 ± 1.0 capillaries/mm). Capillary density was similar in iPAH and hPAH and unrelated to hemodynamics in either PAH or CTEPH. A lower capillary density was predictive of clinical worsening in PAH (p 0.05). After normalization of pulmonary artery pressures by PEA or BPA, capillary density remained reduced in CTEPH patients. Capillary loop apex, capillary and venous- and arterial limb diameter were increased in patients with PAH and CTEPH compared to controls. Nailfold capillary density is reduced to a similar extent in iPAH, hPAH and CTEPH. Normalization of hemodynamics by PEA or BPA does not lead to a restoration of capillary density in CTEPH. Capillary dimensions were increased in both patients with PAH and CTEPH. Lower capillary density was predictive of clinical worsening in PAH. Our findings indicate that a loss of peripheral capillaries is not specific to PAH and is not related to the hemodynamic disturbance per se, but that shared mechanisms may account for a simultaneous development of a systemic microangiopathy and pulmonary vascular remodeling.
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Affiliation(s)
- A J Smits
- Department of Pulmonology, Amsterdam University Medical Center, De Boelelaan 1119, 1081 HV, Amsterdam, The Netherlands
| | - K Isebia
- Department of Vascular Medicine, Amsterdam University Medical Center, De Boelelaan 1119, 1081 HV, Amsterdam, The Netherlands
| | - C Combee-Duffy
- Department of Vascular Medicine, Amsterdam University Medical Center, De Boelelaan 1119, 1081 HV, Amsterdam, The Netherlands
| | - S van der Wal
- Department of Pulmonology, Amsterdam University Medical Center, De Boelelaan 1119, 1081 HV, Amsterdam, The Netherlands
| | - E J Nossent
- Department of Pulmonology, Amsterdam University Medical Center, De Boelelaan 1119, 1081 HV, Amsterdam, The Netherlands
| | - A Boonstra
- Department of Pulmonology, Amsterdam University Medical Center, De Boelelaan 1119, 1081 HV, Amsterdam, The Netherlands
| | - A Vonk-Noordegraaf
- Department of Pulmonology, Amsterdam University Medical Center, De Boelelaan 1119, 1081 HV, Amsterdam, The Netherlands
| | - H J Bogaard
- Department of Pulmonology, Amsterdam University Medical Center, De Boelelaan 1119, 1081 HV, Amsterdam, The Netherlands
| | - E H Serné
- Department of Vascular Medicine, Amsterdam University Medical Center, De Boelelaan 1119, 1081 HV, Amsterdam, The Netherlands.
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2
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Gerges C, Matsubara H, Lang I. Low diffusing capacity for carbon monoxide in chronic thromboembolic pulmonary hypertension: a biomarker for microvascular disease? Heart 2024:heartjnl-2024-324237. [PMID: 39084710 DOI: 10.1136/heartjnl-2024-324237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2024] Open
Affiliation(s)
- Christian Gerges
- Department of Internal Medicine II, Division of Cardiology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Hiromi Matsubara
- Department of Cardiology and Department of Clinical Science, National Hospital Organization, Okayama Medical Centre, Okayama, Japan
| | - Irene Lang
- Department of Internal Medicine II, Division of Cardiology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
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3
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Colebank MJ, Chesler NC. Efficient uncertainty quantification in a spatially multiscale model of pulmonary arterial and venous hemodynamics. Biomech Model Mechanobiol 2024:10.1007/s10237-024-01875-x. [PMID: 39073691 DOI: 10.1007/s10237-024-01875-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 07/11/2024] [Indexed: 07/30/2024]
Abstract
Pulmonary hypertension (PH) is a debilitating disease that alters the structure and function of both the proximal and distal pulmonary vasculature. This alters pressure-flow relationships in the pulmonary arterial and venous trees, though there is a critical knowledge gap in the relationships between proximal and distal hemodynamics in disease. Multiscale computational models enable simulations in both the proximal and distal vasculature. However, model inputs and measured data are inherently uncertain, requiring a full analysis of the sensitivity and uncertainty of the model. Thus, this study quantifies model sensitivity and output uncertainty in a spatially multiscale, pulse-wave propagation model of pulmonary hemodynamics. The model includes fifteen proximal arteries and twelve proximal veins, connected by a two-sided, structured tree model of the distal vasculature. We use polynomial chaos expansions to expedite sensitivity and uncertainty quantification analyses and provide results for both the proximal and distal vasculature. We quantify uncertainty in blood pressure, blood flow rate, wave intensity, wall shear stress, and cyclic stretch. The latter two are important stimuli for endothelial cell mechanotransduction. We conclude that, while nearly all the parameters in our system have some influence on model predictions, the parameters describing the density of the microvascular beds have the largest effects on all simulated quantities in both the proximal and distal arterial and venous circulations.
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Affiliation(s)
- M J Colebank
- Department of Biomedical Engineering, Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center, University of California, Irvine, CA, USA.
| | - N C Chesler
- Department of Biomedical Engineering, Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center, University of California, Irvine, CA, USA
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4
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Simeone B, Maggio E, Schirone L, Rocco E, Sarto G, Spadafora L, Bernardi M, D’Ambrosio L, Forte M, Vecchio D, Valenti V, Sciarretta S, Vizza CD. Chronic Thromboembolic Pulmonary Hypertension: the therapeutic assessment. Front Cardiovasc Med 2024; 11:1439411. [PMID: 39171327 PMCID: PMC11337617 DOI: 10.3389/fcvm.2024.1439411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 07/16/2024] [Indexed: 08/23/2024] Open
Abstract
Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is a severe and complex condition that evolves from unresolved pulmonary embolism, leading to fibrotic obstruction of pulmonary arteries, pulmonary hypertension, and potential right heart failure. The cornerstone of CTEPH management lies in a multifaceted therapeutic approach tailored to individual patient profiles, reflecting the disease's heterogeneity. This review delves into the current therapeutic strategies for CTEPH, including surgical pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA), and targeted pharmacological treatments such as PDE5 inhibitors, endothelin receptor antagonists, sGC stimulators, and prostanoids. Lifelong anticoagulation is also highlighted as a preventive strategy against recurrent thromboembolism. Special emphasis is placed on the interdisciplinary nature of CTEPH care, necessitating collaboration among PEA surgeons, BPA interventionists, PH specialists, and thoracic radiologists to ensure comprehensive treatment planning and execution. The review underscores the importance of selecting an appropriate treatment modality based on the patient's specific disease characteristics and the evolving landscape of CTEPH treatment, aiming to improve patient outcomes through integrated care strategies.
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Affiliation(s)
- Beatrice Simeone
- Department of Cardiology, ICOT Istituto Marco Pasquali, Latina, Italy
| | - Enrico Maggio
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Erica Rocco
- Department of Cardiology, ICOT Istituto Marco Pasquali, Latina, Italy
| | - Gianmarco Sarto
- Department of Cardiology, ICOT Istituto Marco Pasquali, Latina, Italy
| | - Luigi Spadafora
- Department of Cardiology, ICOT Istituto Marco Pasquali, Latina, Italy
| | - Marco Bernardi
- Department of Cardiology, ICOT Istituto Marco Pasquali, Latina, Italy
| | - Luca D’Ambrosio
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Maurizio Forte
- Department of Angiocardioneurology, IRCCS Neuromed, Pozzilli, Italy
| | - Daniele Vecchio
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Valentina Valenti
- Department of Cardiology, Santa Maria Goretti Hospital, Latina, Italy
| | - Sebastiano Sciarretta
- Department of Angiocardioneurology, IRCCS Neuromed, Pozzilli, Italy
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
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5
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Gutor SS, Richmond BW, Agrawal V, Brittain EL, Shaver CM, Wu P, Boyle TK, Mallugari RR, Douglas K, Piana RN, Johnson JE, Miller RF, Newman JH, Blackwell TS, Polosukhin VV. Pulmonary vascular disease in Veterans with post-deployment respiratory syndrome. Cardiovasc Pathol 2024; 71:107640. [PMID: 38604505 DOI: 10.1016/j.carpath.2024.107640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/05/2024] [Accepted: 04/06/2024] [Indexed: 04/13/2024] Open
Abstract
Exertional dyspnea has been documented in US military personnel after deployment to Iraq and Afghanistan. We studied whether continued exertional dyspnea in this patient population is associated with pulmonary vascular disease (PVD). We performed detailed histomorphometry of pulmonary vasculature in 52 Veterans with biopsy-proven post-deployment respiratory syndrome (PDRS) and then recruited five of these same Veterans with continued exertional dyspnea to undergo a follow-up clinical evaluation, including symptom questionnaire, pulmonary function testing, surface echocardiography, and right heart catheterization (RHC). Morphometric evaluation of pulmonary arteries showed significantly increased intima and media thicknesses, along with collagen deposition (fibrosis), in Veterans with PDRS compared to non-diseased (ND) controls. In addition, pulmonary veins in PDRS showed increased intima and adventitia thicknesses with prominent collagen deposition compared to controls. Of the five Veterans involved in our clinical follow-up study, three had borderline or overt right ventricle (RV) enlargement by echocardiography and evidence of pulmonary hypertension (PH) on RHC. Together, our studies suggest that PVD with predominant venular fibrosis is common in PDRS and development of PH may explain exertional dyspnea and exercise limitation in some Veterans with PDRS.
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Affiliation(s)
- Sergey S Gutor
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Bradley W Richmond
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN; Department of Veterans Affairs, Nashville VA, Nashville, TN; Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN
| | - Vineet Agrawal
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Evan L Brittain
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ciara M Shaver
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Pingsheng Wu
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Taryn K Boyle
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ravinder R Mallugari
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Katrina Douglas
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Robert N Piana
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Joyce E Johnson
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Robert F Miller
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - John H Newman
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Timothy S Blackwell
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN; Department of Veterans Affairs, Nashville VA, Nashville, TN; Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN
| | - Vasiliy V Polosukhin
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN.
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Inácio Cazeiro D, Azaredo Raposo M, Guimarães T, Lousada N, Jenkins D, R Inácio J, Moreira S, Mineiro A, Freitas C, Martins S, Ferreira R, Luís R, Cardim N, Pinto FJ, Plácido R. Chronic thromboembolic pulmonary hypertension: A comprehensive review of pathogenesis, diagnosis, and treatment strategies. Rev Port Cardiol 2024:S0870-2551(24)00187-2. [PMID: 38945473 DOI: 10.1016/j.repc.2024.04.006] [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: 11/22/2023] [Revised: 04/09/2024] [Accepted: 04/17/2024] [Indexed: 07/02/2024] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is part of group 4 of the pulmonary hypertension (PH) classification and generally affects more than a third of patients referred to PH centers. It is a three-compartment disease involving proximal (lobar-to-segmental) and distal (subsegmental) pulmonary arteries that are obstructed by persistent fibrothrombotic material, and precapillary pulmonary arteries that can be affected as in pulmonary arterial hypertension. It is a rare complication of pulmonary embolism (PE), with an incidence of around 3% in PE survivors. The observed incidence of CTEPH in the general population is around six cases per million but could be three times higher than this, as estimated from PE incidence. However, a previous venous thromboembolic episode is not always documented. With advances in multimodality imaging and therapeutic management, survival for CTEPH has improved for both operable and inoperable patients. Advanced imaging with pulmonary angiography helps distinguish proximal from distal obstructive disease. However, right heart catheterization is of utmost importance to establish the diagnosis and hemodynamic severity of PH. The therapeutic strategy relies on a stepwise approach, starting with an operability assessment. Pulmonary endarterectomy (PEA), also known as pulmonary thromboendarterectomy, is the first-line treatment for operable patients. Growing experience and advances in surgical technique have enabled expansion of the distal limits of PEA and significant improvements in perioperative and mid- to long-term mortality. In patients who are inoperable or who have persistent/recurrent PH after PEA, medical therapy and/or balloon pulmonary angioplasty (BPA) are effective treatment options with favorable outcomes that are increasingly used. All treatment decisions should be made with a multidisciplinary team that includes a PEA surgeon, a BPA expert, and a chest radiologist.
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Affiliation(s)
- Daniel Inácio Cazeiro
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Miguel Azaredo Raposo
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Tatiana Guimarães
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Nuno Lousada
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - David Jenkins
- Cardiothoracic Surgery Department, Royal Papworth Hospital, Cambridge, UK
| | - João R Inácio
- Radiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Susana Moreira
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Ana Mineiro
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Céline Freitas
- Association for Research and Development of Faculty of Medicine (AIDFM), Cardiovascular Research Support Unit (GAIC), Lisbon, Portugal
| | - Susana Martins
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Ricardo Ferreira
- Cardiothoracic Surgery Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Rita Luís
- Pathology Department, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Nuno Cardim
- Cardiology Department, CUF Descobertas Hospital, Lisbon, Portugal
| | - Fausto J Pinto
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Rui Plácido
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal; Cardiology Department, CUF Descobertas Hospital, Lisbon, Portugal.
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7
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Lu J, Alenezi F, Bier E, Leewiwatwong S, Mummy D, Kabir S, Rajagopal S, Robertson S, Niedbalski PJ, Driehuys B. Optimized quantitative mapping of cardiopulmonary oscillations using hyperpolarized 129 Xe gas exchange MRI: Digital phantoms and clinical evaluation in CTEPH. Magn Reson Med 2024; 91:1541-1555. [PMID: 38084439 PMCID: PMC10872359 DOI: 10.1002/mrm.29965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 02/03/2024]
Abstract
PURPOSE The interaction between 129 Xe atoms and pulmonary capillary red blood cells provides cardiogenic signal oscillations that display sensitivity to precapillary and postcapillary pulmonary hypertension. Recently, such oscillations have been spatially mapped, but little is known about optimal reconstruction or sensitivity to artifacts. In this study, we use digital phantom simulations to specifically optimize keyhole reconstruction for oscillation imaging. We then use this optimized method to re-establish healthy reference values and quantitatively evaluate microvascular flow changes in patients with chronic thromboembolic pulmonary hypertension (CTEPH) before and after pulmonary thromboendarterectomy (PTE). METHODS A six-zone digital lung phantom was designed to investigate the effects of radial views, key radius, and SNR. One-point Dixon 129 Xe gas exchange MRI images were acquired in a healthy cohort (n = 17) to generate a reference distribution and thresholds for mapping red blood cell oscillations. These thresholds were applied to 10 CTEPH participants, with 6 rescanned following PTE. RESULTS For undersampled acquisitions, a key radius of0.14 k max $$ 0.14{k}_{\mathrm{max}} $$ was found to optimally resolve oscillation defects while minimizing excessive heterogeneity. CTEPH participants at baseline showed higher oscillation defect + low (32 ± 14%) compared with healthy volunteers (18 ± 12%, p < 0.001). For those scanned both before and after PTE, oscillation defect + low decreased from 37 ± 13% to 23 ± 14% (p = 0.03). CONCLUSIONS Digital phantom simulations have informed an optimized keyhole reconstruction technique for gas exchange images acquired with standard 1-point Dixon parameters. Our proposed methodology enables more robust quantitative mapping of cardiogenic oscillations, potentially facilitating effective regional quantification of microvascular flow impairment in patients with pulmonary vascular diseases such as CTEPH.
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Affiliation(s)
- Junlan Lu
- Medical Physics Graduate Program, Duke University, Durham, North Carolina, USA
| | - Fawaz Alenezi
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Elianna Bier
- Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | | | - David Mummy
- Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Sakib Kabir
- Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Scott Robertson
- Clinical Imaging Physics Group, Duke University Medical Center, Durham, North Carolina, USA
| | - Peter J. Niedbalski
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Bastiaan Driehuys
- Medical Physics Graduate Program, Duke University, Durham, North Carolina, USA
- Biomedical Engineering, Duke University, Durham, North Carolina, USA
- Radiology, Duke University Medical Center, Durham, North Carolina, USA
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8
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Constantine A, Dimopoulos K, Gerges C, Lang IM. Peripheral pulmonary artery stenosis in adults: a novel type of pulmonary vascular disease with a strong genetic background. Eur Respir J 2023; 62:2302085. [PMID: 38128952 DOI: 10.1183/13993003.02085-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Andrew Constantine
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Christian Gerges
- Department of Cardiology, Medical University of Vienna, Comprehensive Center for Cardiovascular Medicine, Vienna, Austria
| | - Irene M Lang
- Department of Cardiology, Medical University of Vienna, Comprehensive Center for Cardiovascular Medicine, Vienna, Austria
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9
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Delcroix M, de Perrot M, Jaïs X, Jenkins DP, Lang IM, Matsubara H, Meijboom LJ, Quarck R, Simonneau G, Wiedenroth CB, Kim NH. Chronic thromboembolic pulmonary hypertension: realising the potential of multimodal management. THE LANCET. RESPIRATORY MEDICINE 2023; 11:836-850. [PMID: 37591299 DOI: 10.1016/s2213-2600(23)00292-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/13/2023] [Accepted: 07/24/2023] [Indexed: 08/19/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism. Important advances have enabled better understanding, characterisation, and treatment of this condition. Guidelines recommending systematic follow-up after acute pulmonary embolism, and the insight that CTEPH can mimic acute pulmonary embolism on initial presentation, have led to the definition of CTEPH imaging characteristics, the introduction of artificial intelligence diagnosis pathways, and thus the prospect of easier and earlier CTEPH diagnosis. In this Series paper, we show how the understanding of CTEPH as a sequela of inflammatory thrombosis has driven successful multidisciplinary management that integrates surgical, interventional, and medical treatments. We provide imaging examples of classical major vessel targets, describe microvascular targets, define available tools, and depict an algorithm facilitating the initial treatment strategy in people with newly diagnosed CTEPH based on a multidisciplinary team discussion at a CTEPH centre. Further work is needed to optimise the use and combination of multimodal therapeutic options in CTEPH to improve long-term outcomes for patients.
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Affiliation(s)
- Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven-University of Leuven, Leuven, Belgium.
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Xavier Jaïs
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Irene M Lang
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Centre for CardioVascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Rozenn Quarck
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven-University of Leuven, Leuven, Belgium
| | - Gérald Simonneau
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | - Nick H Kim
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
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10
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Haner Wasserstein D, Frishman WH. Impact of Balloon Pulmonary Angioplasty on Right Ventricular Function in Patients With Chronic Thromboembolic Pulmonary Hypertension. Cardiol Rev 2023:00045415-990000000-00133. [PMID: 37607033 DOI: 10.1097/crd.0000000000000571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) can develop in some patients after an acute pulmonary embolism. The disease is characterized by the conversion of emboli into fibrotic thrombi that chronically impede normal circulation through the pulmonary arteries and increase pulmonary vascular resistance. Over time, this increases right ventricular (RV) afterload and strains the RV. The RV compensates by undergoing cardiomyocyte hypertrophy and RV dilation that can maintain stroke volume. However, these adaptations eventually decrease cardiac output and lead to right heart failure. Balloon pulmonary angioplasty has been developed as a treatment option for CTEPH by systematically disrupting thrombosed vessels and improving blood flow throughout the pulmonary circulation. This ultimately reverses the structural maladaptation's seen in CTEPH and improves RV function.
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Affiliation(s)
| | - William H Frishman
- Department of Medicine, New York Medical College/Westchester Medical Center, Valhalla, NY
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11
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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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Affiliation(s)
- Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Center for Cardiovascular Medicine, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven, ON1bis Herestraat 49 - box 707, 3000 Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven-University of Leuven, ON1bis Herestraat 49 - box 707, 3000 Leuven, Belgium
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13
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D'Armini AM, Pin M, Celentano A, Te Masiglat LJ, Borrelli E, Vanini B, Klersy C, Silvaggio G, Monterosso C, Alloni A, Pellegrini C, Ghio S. Pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension: Relationship between treated branches and outcome. Int J Cardiol 2023; 377:124-130. [PMID: 36642333 DOI: 10.1016/j.ijcard.2023.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/12/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND In patients with chronic thromboembolic pulmonary hypertension (CTEPH) undergoing pulmonary endarterectomy (PEA) it is important to minimize residual obstructions, in order to achieve low postoperative pulmonary vascular resistances and better clinical results. The aim of the study was to test the hypothesis that the greater the number of pulmonary artery branches treated at surgery, the better the hemodynamic and clinical outcome after PEA. METHODS In 564 consecutive CTEPH patients undergoing PEA the count of the number of treated branches was performed directly on the surgical specimens. Post-operative follow-up visits were scheduled at 3 months and 12 months after surgery including right heart catheterization and modified Bruce test. RESULTS The population was divided into tertiles based on the number of treated branches: Group 1 (from 4 to 30 treated branches, n = 194 patients); Group 2 (from 31 to 43 treated branches, n = 190 patients); Group 3 (from 44 to 100 treated branches, n = 180 patients). At 3 and at 12 months after PEA, after adjustment for confounders, patients in the highest tertile of treated branches had significantly lower values of pulmonary vascular resistance and higher values of pulmonary arterial compliance as compared to the other two groups (p < 0.002). Hospital mortality was 3% in Group 3, 6% in Group 2 and 10% in Group 1 (overall p = 0.035). CONCLUSIONS In CTEPH patients undergoing PEA, a higher number of treated pulmonary artery branches is associated with a better hemodynamic and a better clinical outcome at 3 months and 12 months after surgery.
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Affiliation(s)
- Andrea M D'Armini
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy; Division of Cardiac Surgery 2 and Pulmonary Hypertension Center, Foundation IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Maurizio Pin
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy
| | - Anna Celentano
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy
| | - Leslie J Te Masiglat
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy
| | - Ermelinda Borrelli
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy
| | - Benedetta Vanini
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy
| | - Catherine Klersy
- Service of Clinical Epidemiology and Biometry, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giuseppe Silvaggio
- Division of Cardiac Surgery 1, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Cristian Monterosso
- Division of Cardiac Surgery 1, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessia Alloni
- Division of Cardiac Surgery 1, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carlo Pellegrini
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy; Division of Cardiac Surgery 1, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Stefano Ghio
- Division of Cardiology, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
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14
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Lang IM. Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension: Clinical Outcomes. Eur Cardiol 2023. [DOI: 10.15420/ecr.2022.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare major vessel pulmonary vascular disease that is characterised by fibrotic obstructions deriving from an organised clot. Recent advances in treatments for CTEPH have significantly improved outcomes. Apart from classical surgical pulmonary endarterectomy, balloon pulmonary angioplasty (BPA) and vasodilator drugs that were tested in randomised controlled trials of non-operable patients are now available. In Europe, CTEPH affects males and females equally. In the first European CTEPH Registry, women with CTEPH underwent pulmonary endarterectomy less frequently than men, especially at low-volume centres. In Japan, CTEPH is more common in females and is predominantly treated by BPA. More data on gender-specific outcomes are expected from the results of the International BPA Registry (NCT03245268).
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Affiliation(s)
- Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
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15
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Inhibition of heterogeneous nuclear ribonucleoproteins A1 and oxidative stress reduces glycolysis via pyruvate kinase M2 in chronic thromboembolic pulmonary hypertension. J Transl Int Med 2023. [DOI: 10.2478/jtim-2022-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
Abstract
Background and Objective
Chronic thromboembolic pulmonary hypertension (CTEPH) is a lethal complication of pulmonary embolism involving pulmonary artery occlusion and microvascular disease. The glucose metabolism and reactive oxygen species (ROS) production may be perturbed in CTEPH, but the precise mechanisms are unclear. This study investigated glucose metabolism in CTEPH employing pulmonary endarterectomy (PEA)-derived pulmonary artery smooth muscle cells (PASMCs) and characterized the roles of pyruvate kinase M2 (PKM2) and its regulation by heterogeneous nuclear ribonucleoproteins A1 (hnRNPA1) and ROS in CTEPH.
Methods
PEA tissues and blood samples of CTEPH patients were collected to study the levels of PKM2. Primary PASMCs were isolated from PEA tissues. We used small interfering RNAs to knock down PKM2 and hnRNPA1, and applied antioxidant N-acetylcysteine (NAC) and mito-TEMPO to reduce ROS production. The expression of glucometabolic genes, ROS production, glycolysis rate and proliferative and migratory activities were analyzed in PEA-derived PASMCs.
Results
PKM2 levels in serum and PEA tissues of CTEPH patients were higher than that of the healthy controls. Compared to the control PASMCs, PEA-derived PASMCs showed increased PKM2 expression and ROS production. The rates of glycolysis, proliferation and migration were increased in PEA-PASMCs and could be mitigated by PKM2 downregulation through hnRNPA1 or ROS inhibition.
Conclusions
Increased glycolysis and PKM2 expression were found in PEA-PASMCs. Inhibition of hnRNPA1 or ROS corrected the aberrant glycolysis, cell proliferation and migration by downregulating PKM2. Regulation of the hnRNPA1/PKM2 axis represents a potential therapeutic target for the treatment of CTEPH.
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16
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Gerges C, Pistritto AM, Gerges M, Friewald R, Hartig V, Hofbauer TM, Reil B, Engel L, Dannenberg V, Kastl SP, Skoro-Sajer N, Moser B, Taghavi S, Klepetko W, Lang IM. Left Ventricular Filling Pressure in Chronic Thromboembolic Pulmonary Hypertension. J Am Coll Cardiol 2023; 81:653-664. [PMID: 36792280 DOI: 10.1016/j.jacc.2022.11.049] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by obstruction of major pulmonary arteries with organized thrombi. Clinical risk factors for pulmonary hypertension due to left heart disease including metabolic syndrome, left-sided valvular heart disease, and ischemic heart disease are common in CTEPH patients. OBJECTIVES The authors sought to investigate prevalence and prognostic implications of elevated left ventricular filling pressures (LVFP) in CTEPH. METHODS A total of 593 consecutive CTEPH patients undergoing a first diagnostic right and left heart catheterization were included in this study. Mean pulmonary arterial wedge pressure (mPAWP) and left ventricular end-diastolic pressure (LVEDP) were utilized for assessment of LVFP. Two cutoffs were applied to identify patients with elevated LVFP: 1) for the primary analysis mPAWP and/or LVEDP >15 mm Hg, as recommended by the current pulmonary hypertension guidelines; and 2) for the secondary analysis mPAWP and/or LVEDP >11 mm Hg, representing the upper limit of normal. Clinical and echocardiographic features, and long-term mortality were assessed. RESULTS LVFP was >15 mm Hg in 63 (10.6%) and >11 mm Hg in 222 patients (37.4%). Univariable logistic regression analysis identified age, systemic hypertension, diabetes, atrial fibrillation, calcific aortic valve stenosis, mitral regurgitation, and left atrial volume as significant predictors of elevated LVFP. Atrial fibrillation, calcific aortic valve stenosis, mitral regurgitation, and left atrial volume remained independent determinants of LVFP in adjusted analysis. At follow-up, higher LVFPs were measured in patients who had meanwhile undergone pulmonary endarterectomy (P = 0.002). LVFP >15 mm Hg (P = 0.021) and >11 mm Hg (P = 0.006) were both associated with worse long-term survival. CONCLUSIONS Elevated LVFP is common, appears to be due to comorbid left heart disease, and predicts prognosis in CTEPH.
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Affiliation(s)
- Christian Gerges
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | - Mario Gerges
- Department of Internal Medicine V, Division of Cardiology, Clinic Favoriten, Vienna, Austria
| | - Richard Friewald
- Department of Internal Medicine I, Division of Cardiology, University Hospital of Krems, Krems an der Donau, Austria; Karl Landsteiner Private University for Health Sciences, Krems an der Donau, Austria
| | - Valerie Hartig
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Thomas M Hofbauer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Benedikt Reil
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Leon Engel
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Varius Dannenberg
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Stefan P Kastl
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Nika Skoro-Sajer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Bernhard Moser
- Department of Surgery, Division of Thoracic Surgery, Medical University Vienna, Vienna, Austria
| | - Shahrokh Taghavi
- Department of Surgery, Division of Thoracic Surgery, Medical University Vienna, Vienna, Austria
| | - Walter Klepetko
- Department of Surgery, Division of Thoracic Surgery, Medical University Vienna, Vienna, Austria
| | - Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria.
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Vahdatpour C, Epstein S, Jones K, Smoot M, Parker A, Ryan J, Bryant A. A review of cardio-pulmonary microvascular dysfunction in pulmonary hypertension. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 26:100255. [PMID: 38510189 PMCID: PMC10946046 DOI: 10.1016/j.ahjo.2023.100255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/16/2023] [Accepted: 01/19/2023] [Indexed: 03/22/2024]
Abstract
Microvascular dysfunction progressing to pulmonary hypertension can be a primary cause of right ventricular failure or a secondary cause because of an underlying systemic illness. Little is known regarding the etiology and epidemiology of coronary microvascular dysfunction in pulmonary hypertension. Despite this limitation, its presence has been described in patients with pulmonary hypertension. This review focuses on the pathogenesis of cardiac and pulmonary microvascular dysfunction in pulmonary hypertension. Additionally, this review provides a contemporary assessment on the diagnosis and treatment of microvascular dysfunction in patients in pulmonary hypertension. This topic is important to raise awareness of microvascular dysfunction in the coronary and pulmonary circulation, so that future studies will investigate its impact on the pulmonary hypertension patient cohort.
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Affiliation(s)
- Cyrus Vahdatpour
- Department of Pulmonary Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, USA
| | - Samuel Epstein
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Kirk Jones
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Madeline Smoot
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Alex Parker
- Department of Cardiology, University of Florida, Gainesville, FL, USA
| | - John Ryan
- Department of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, USA
| | - Andrew Bryant
- Department of Pulmonary Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, USA
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Marchetta S, Verbelen T, Claessen G, Quarck R, Delcroix M, Godinas L. A Comprehensive Assessment of Right Ventricular Function in Chronic Thromboembolic Pulmonary Hypertension. J Clin Med 2022; 12:jcm12010047. [PMID: 36614845 PMCID: PMC9821031 DOI: 10.3390/jcm12010047] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
While chronic thromboembolic pulmonary hypertension (CTEPH) results from macroscopic and microscopic obstruction of the pulmonary vascular bed, the function of the right ventricle (RV) and increased RV afterload are the main determinants of its symptoms and prognosis. In this review, we assess RV function in patients diagnosed with CTEPH with a focus on the contributions of RV afterload and dysfunction to the pathogenesis of this disease. We will also discuss changes in RV function and geometry in response to treatment, including medical therapy, pulmonary endarterectomy, and balloon pulmonary angioplasty.
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Affiliation(s)
| | - Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Guido Claessen
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Rozenn Quarck
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chonic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
| | - Marion Delcroix
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chonic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
- Department of Pneumology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Laurent Godinas
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chonic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
- Department of Pneumology, University Hospitals Leuven, 3000 Leuven, Belgium
- Correspondence:
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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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Jaïs X, Brenot P, Bouvaist H, Jevnikar M, Canuet M, Chabanne C, Chaouat A, Cottin V, De Groote P, Favrolt N, Horeau-Langlard D, Magro P, Savale L, Prévot G, Renard S, Sitbon O, Parent F, Trésorier R, Tromeur C, Piedvache C, Grimaldi L, Fadel E, Montani D, Humbert M, Simonneau G. Balloon pulmonary angioplasty versus riociguat for the treatment of inoperable chronic thromboembolic pulmonary hypertension (RACE): a multicentre, phase 3, open-label, randomised controlled trial and ancillary follow-up study. THE LANCET RESPIRATORY MEDICINE 2022; 10:961-971. [DOI: 10.1016/s2213-2600(22)00214-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 05/12/2022] [Accepted: 05/19/2022] [Indexed: 01/05/2023]
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21
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Is Pulmonary Artery Pulsatility Index (PAPi) a Predictor of Outcome after Pulmonary Endarterectomy? J Clin Med 2022; 11:jcm11154353. [PMID: 35955972 PMCID: PMC9368812 DOI: 10.3390/jcm11154353] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/06/2022] [Accepted: 06/20/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Pulmonary endarterectomy (PEA) is the gold standard therapy for chronic thromboembolic pulmonary hypertension (CTEPH). Traditionally, pulmonary vascular resistance (PVR) represents the main prognostic factor after surgery. The pulmonary artery pulsatility index (PAPi) has been proposed for the assessment of RV in advanced heart failure, but it has never been applied in CTEPH patients. The aim of the present study is to describe PAPi in patients who underwent PEA, before and after surgery, and to define its predictive impact on postoperative outcomes. Methods: We retrospectively reviewed 188 consecutive adult patients who underwent PEA, between December 2003 and December 2021. PAPi was calculated for 186 patients and reported. Patients were partitioned in two groups using median preoperative PAPi as cutoff value: Group 1 with PAPi ≤ 8.6 (n = 94) and Group 2 with PAPi > 8.6 (n = 92). The propensity-score-matched analysis identified 67 pairs: Early outcomes were compared between two groups. Results: Mean preoperative PAPi was 10.3 ± 7.2. Considering matched populations, no differences emerged in terms of postoperative hemodynamics; Group 1 demonstrated higher 90-day mortality significance (10.4% vs. 3.0%, p = 0.082); the need for mechanical circulatory support (MCS) was similar, but successful weaning was unlikely (25% vs. 85.7%, p = 0.032). Conclusions: Mean PAPi in the CTEPH population is higher than in other diseases. Low PAPi (≤8.6) seems to be associated with lower postoperative survival and successful weaning from MCS.
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed, but potentially curable pulmonary vascular disease. The increased pulmonary vascular resistance in CTEPH is caused by unresolved proximal thrombus and secondary microvasculopathy in the pulmonary vasculature, leading to adaptive and maladaptive remodeling of the right ventricle (RV), eventual right heart failure, and death. Knowledge on the RV remodeling process in CTEPH is limited. The progression to RV failure in CTEPH is a markedly slower process. A detailed understanding of the pathophysiology and underlying mechanisms of RV remodeling may facilitate early diagnosis and the development of targeted therapy. While ultrasound, magnetic resonance imaging, right heart catheterization, and serum biomarkers have been used to assess cardiac function, the current treatment strategies reduce the afterload of the right heart, but are less effective in improving the maladaptive remodeling of the right heart. This review systematically summarizes the current knowledge on adaptive and maladaptive remodeling of the right heart in CTEPH from molecular mechanisms to clinical practice.
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Boehm PM, Schwarz S, Thanner J, Veraar C, Gerges M, Gerges C, Lang I, Apfaltrer P, Prosch H, Taghavi S, Klepetko W, Ankersmit HJ, Moser B. Larger pulmonary artery to ascending aorta ratios are associated with decreased survival of patients undergoing pulmonary endarterectomy. JTCVS OPEN 2022; 10:62-72. [PMID: 36004247 PMCID: PMC9390379 DOI: 10.1016/j.xjon.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 02/17/2022] [Indexed: 11/25/2022]
Abstract
Objectives The ratio of pulmonary artery (PA) and ascending aorta (AA) diameters has recently been shown to be a useful indicator for disease severity and predictor of outcome in patients with pulmonary hypertension and heart failure. This study aimed at evaluating the applicability of this ratio for perioperative risk assessment of patients with chronic thromboembolic pulmonary hypertension undergoing pulmonary endarterectomy. Methods In this retrospective cohort study on 149 patients undergoing pulmonary endarterectomy between 2013 and 2020, the preoperative PA to AA ratio was analyzed on axial computed tomography. Variables of pulmonary hemodynamic status were assessed during preoperative right heart catheterization and postoperative Swan-Ganz catheter measurements. Perioperative survival was analyzed by Kaplan-Meier method and log-rank tests. Results Preoperative computed tomography measurements showed a median AA diameter of 31 mm (range, 19-47 mm), and a median PA diameter of 36 mm (range, 25-55 mm). The calculated median PA to AA ratio was 1.13 (range, 0.79-1.80). PA to AA ratio correlated positively with PA pressure (systolic, r = 0.352 [P < .001]; diastolic, r = 0.406 [P < .001]; mean, r = 0.318 [P < .001]) and inversely with age (r = −0.484 [P < .001]). Univariable Cox regression analysis identified PA diameter (P = .008) as a preoperative parameter predictive of survival. There was a significant difference (log-rank P = .037) in 30-day survival probability for patients with lower PA to AA ratios (<1.136; survival probability, 97.4%) compared with patients with higher ratios (>1.136; survival probability, 88.9%). Conclusions PA to AA ratio shows a correlation with other variables associated with pulmonary hypertension. In addition, patients with higher PA to AA ratios have lower survival probabilities after PEA. Further analysis of PA to AA ratio on the selection of chronic thromboembolic pulmonary hypertension for different treatment modalities—pulmonary endarterectomy, medical therapy, and or balloon pulmonary angioplasty—is warranted.
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Affiliation(s)
- Panja M. Boehm
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Schwarz
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Jürgen Thanner
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Cecilia Veraar
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Mario Gerges
- Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christian Gerges
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Irene Lang
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Paul Apfaltrer
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Shahrokh Taghavi
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Walter Klepetko
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Bernhard Moser
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
- Address for reprints: Bernhard Moser, MD, PhD, MBA, Department of Thoracic Surgery, Medical University of Vienna, Austria, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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24
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Piliero N, Thony F, Guillien A, Rousseau J, Finas M, Vautrin E, Degano B, Bouvaist H. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: Evaluation of haemodynamic effects, complication rates and radiation exposure over time. Arch Cardiovasc Dis 2022; 115:295-304. [DOI: 10.1016/j.acvd.2022.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 02/18/2022] [Accepted: 02/21/2022] [Indexed: 11/02/2022]
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25
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Simonneau G, Dorfmüller P, Guignabert C, Mercier O, Humbert M. Chronic thromboembolic pulmonary hypertension: the magic of pathophysiology. Ann Cardiothorac Surg 2022; 11:106-119. [PMID: 35433354 PMCID: PMC9012195 DOI: 10.21037/acs-2021-pte-10] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 08/26/2021] [Indexed: 08/19/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and underdiagnosed complication of acute pulmonary embolism (APE). CTEPH is a common cause of pulmonary hypertension (PH) with distinct management strategy including pulmonary endarterectomy, balloon pulmonary angioplasty, long-term anticoagulation and PH drugs targeting endothelial cell dysfunction. Initially, PH in chronic thromboembolic pulmonary disease (CTEPD) was thought to be due exclusively to the intravascular obstruction of pulmonary arteries by unresolved fibrotic clots. However, it is now well accepted that pulmonary vascular remodelling can include significant pulmonary microvasculopathy, which plays a role in the development of CTEPH. The histological description and clinical consequences of CTEPH microvasculopathy are now better understood. These lesions may involve not only small muscular pulmonary arteries <500 µm, but also pulmonary capillaries and veins. In addition, enlargement and proliferation of systemic bronchial arteries as well as anastomoses between the systemic and pulmonary circulations contribute to the development of microvasculopathy. In this review, we discuss the recent advances in the understanding of the pathophysiology of CTEPH.
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Affiliation(s)
- Gérald Simonneau
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique Hôpitaux de Paris, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension Referral Centre, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Department of Thoracic and Vascular Surgery, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Le Plessis-Robinson, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Peter Dorfmüller
- Department of Pathology, University Hospital Giessen/Marburg, Giessen, Germany
- German Centre for Lung Research (DZL), Giessen, Germany
| | - Christophe Guignabert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Olaf Mercier
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Department of Thoracic and Vascular Surgery, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Le Plessis-Robinson, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique Hôpitaux de Paris, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension Referral Centre, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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26
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Chaudhary M. Novel methylation mark and essential hypertension. JOURNAL OF GENETIC ENGINEERING AND BIOTECHNOLOGY 2022; 20:11. [PMID: 35061109 PMCID: PMC8777530 DOI: 10.1186/s43141-022-00301-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 01/14/2022] [Indexed: 12/11/2022]
Abstract
Background Essential hypertension (EH) is an important risk factor for various cardiovascular, cerebral and renal disorders. It is a multi-factorial trait which occurs through complex interplay between genetic, epigenetic, and environmental factors. Even after advancement of technology and deciphering the involvement of multiple signalling pathways in blood pressure regulation, it still remains as a huge global concern. Main body of the abstract Genome-wide association studies (GWAS) have revealed EH-associated genetic variants but these solely cannot explain the variability in blood pressure indicating the involvement of additional factors. The etiopathogenesis of hypertension has now advanced to the level of epigenomics where aberrant DNA methylation is the most defined epigenetic mechanism to be involved in gene regulation. Though role of DNA methylation in cancer and other mechanisms is deeply studied but this mechanism is in infancy in relation to hypertension. Generally, 5-methylcytosine (5mC) levels are being targeted at both individual gene and global level to find association with the disease. But recently, with advanced sequencing techniques another methylation mark, N6-methyladenine (6mA) was found and studied in humans which was earlier considered to be absent in case of eukaryotes. Relation of aberrant 6mA levels with cancer and stem cell fate has drawn attention to target 6mA levels with hypertension too. Conclusion Recent studies targeting hypertension has suggested 6mA levels as novel marker and its demethylase, ALKBH1 as probable therapeutic target to prevent hypertension through epigenetic programming. This review compiles different methylation studies and suggests targeting of both 5mC and 6mA levels to cover role of methylation in hypertension in broader scenario.
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27
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Systemic-pulmonary collateral supply associated with clinical severity of chronic thromboembolic pulmonary hypertension: a study using intra-aortic computed tomography angiography. Eur Radiol 2022; 32:7668-7679. [PMID: 35420297 PMCID: PMC9668953 DOI: 10.1007/s00330-022-08768-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 03/11/2022] [Accepted: 03/23/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To assess whether systemic-pulmonary collaterals are associated with clinical severity and extent of pulmonary perfusion defects in chronic thromboembolic pulmonary hypertension (CTEPH). METHODS This prospective study was approved by a local ethics committee. Twenty-four patients diagnosed with inoperable CTEPH were enrolled between July 2014 and February 2017. Systemic-pulmonary collaterals were detected using pulmonary vascular enhancement on intra-aortic computed tomography (CT) angiography. The pulmonary enhancement parameters were calculated, including (1) Hounsfield unit differences (HUdiff) between pulmonary trunks and pulmonary arteries (PAs) or veins (PVs), namely HUdiff-PA and HUdiff-PV, on the segmental base; (2) the mean HUdiff-PA, mean HUdiff-PV, numbers of significantly enhanced PAs and PVs, on the patient base. Pulmonary perfusion defects were recorded and scored using the lung perfused blood volume (PBV) based on intravenous dual-energy CT (DECT) angiography. Pearson's or Spearman's correlation coefficients were used to evaluate correlations between the following: (1) segment-based intra-aortic CT and intravenous DECT parameters (2) patient-based intra-aortic CT parameters and clinical severity parameters or lung PBV scores. Statistical significance was set at p < 0.05. RESULTS Segmental HUdiff-PV was correlated with the segmental perfusion defect score (r = 0.45, p < 0.01). The mean HUdiff-PV was correlated with the mean pulmonary arterial pressure (PAP) (r = 0.52, p < 0.01), cardiac output (rho = - 0.41, p = 0.05), and lung PBV score (rho = 0.43, p = 0.04). And the number of significantly enhanced PVs was correlated with the mean PAP (r = 0.54, p < 0.01), pulmonary vascular resistance (r = 0.54, p < 0.01), and lung PBV score (rho = 0.50, p = 0.01). CONCLUSIONS PV enhancement measured by intra-aortic CT angiography reflects clinical severity and pulmonary perfusion defects in CTEPH. KEY POINTS • Intra-aortic CT angiography demonstrated heterogeneous enhancement within the pulmonary vasculature, showing collaterals from the systemic arteries to the pulmonary circulation in CTEPH. • The degree of systemic-pulmonary collateral development was significantly correlated with the clinical severity of CTEPH and may be used to evaluate disease progression. • The distribution of systemic-pulmonary collaterals is positively correlated with perfusion defects in the lung segments in CTEPH.
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28
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Li X, Zhang Y, Luo Q, Zhao Q, Zeng Q, Yang T, Jin Q, Yan L, Duan A, Liu J, An C, Ma X, Xiong C, Zhao Z, Liu Z. Diffusing Capacity for Carbon Monoxide Predicts Response to Balloon Pulmonary Angioplasty in Patients With Inoperable Chronic Thromboembolic Pulmonary Hypertension. Front Cardiovasc Med 2021; 8:762267. [PMID: 34926612 PMCID: PMC8674470 DOI: 10.3389/fcvm.2021.762267] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/02/2021] [Indexed: 01/01/2023] Open
Abstract
Background: The hemodynamic results of balloon pulmonary angioplasty vary among patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Previous studies revealed that microvasculopathy accounted for residual pulmonary hypertension after pulmonary endarterectomy, which could be reflected by the diffusing capacity for carbon monoxide (DLCO). We aimed to identify whether the DLCO could predict the BPA response. Materials and Methods: We retrospectively analyzed 75 consecutive patients with inoperable CTEPH who underwent BPA from May 2018 to January 2021 at Fuwai Hospital. According to the hemodynamics at follow-up after the last BPA, patients were classified as “BPA responders” (defined as a mean pulmonary arterial pressure ≤ 30 mmHg and/or a reduction of pulmonary vascular resistance ≥ 30%) or “BPA nonresponders.” Results: At the baseline, BPA responders had significantly higher DLCO values than nonresponders, although the other variables were comparable. In BPA responders, the DLCO decreased after the first BPA session and then returned to a level similar to the baseline at follow-up. Conversely, the DLCO increased constantly from the baseline to follow-up in nonresponders. Multivariate logistic analysis showed that a baseline DLCO of <70% and a percent change in DLCO between the baseline and the period within 7 days after the first BPA session (ΔDLCO) of > 6% were both independent predictors of an unfavorable response to BPA. Receiver operator characteristic analysis showed that the combination of a baseline DLCO < 70% and ΔDLCO > 6% demonstrated a better area under the curve than either of these two variables used alone. Conclusions: A baseline DLCO < 70% and ΔDLCO > 6% could independently predict unfavorable responses to BPA. Measuring the DLCO dynamically facilitates the identification of patients who might have unsatisfactory hemodynamic results after BPA.
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Affiliation(s)
- Xin Li
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Zhang
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qing Zhao
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qixian Zeng
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Yang
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qi Jin
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lu Yan
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Anqi Duan
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiaran Liu
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chenhong An
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiuping Ma
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Changming Xiong
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhihui Zhao
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Affiliation(s)
- Paul M Hassoun
- From the Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
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30
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Klok FA, Ageno W, Ay C, Bäck M, Barco S, Bertoletti L, Becattini C, Carlsen J, Delcroix M, van Es N, Huisman MV, Jara-Palomares L, Konstantinides S, Lang I, Meyer G, Ní Áinle F, Rosenkranz S, Pruszczyk P. Optimal follow-up after acute pulmonary embolism: a position paper of the European Society of Cardiology Working Group on Pulmonary Circulation and Right Ventricular Function, in collaboration with the European Society of Cardiology Working Group on Atherosclerosis and Vascular Biology, endorsed by the European Respiratory Society. Eur Heart J 2021; 43:183-189. [PMID: 34875048 PMCID: PMC8790766 DOI: 10.1093/eurheartj/ehab816] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/22/2021] [Accepted: 11/12/2021] [Indexed: 12/11/2022] Open
Abstract
This position paper provides a comprehensive guide for optimal follow-up of patients with acute pulmonary embolism (PE), covering multiple relevant aspects of patient counselling. It serves as a practical guide to treating patients with acute PE complementary to the formal 2019 European Society of Cardiology guidelines developed with the European Respiratory Society. We propose a holistic approach considering the whole spectrum of serious adverse events that patients with acute PE may encounter on the short and long run. We underline the relevance of assessment of modifiable risk factors for bleeding, of acquired thrombophilia and limited cancer screening (unprovoked PE) as well as a dedicated surveillance for the potential development of chronic thromboembolic pulmonary hypertension as part of routine practice; routine testing for genetic thrombophilia should be avoided. We advocate the use of outcome measures for functional outcome and quality of life to quantify the impact of the PE diagnosis and identify patients with the post-PE syndrome early. Counselling patients on maintaining a healthy lifestyle mitigates the risk of the post-PE syndrome and improves cardiovascular prognosis. Therefore, we consider it important to discuss when and how to resume sporting activities soon after diagnosing PE. Additional patient-relevant topics that require Focused counselling are travel and birth control.
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Affiliation(s)
- Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands.,Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.,I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Magnus Bäck
- Center for Molecular Medicine and Department of Cardiology, Karolinska University Hospital, Solna, Sweden, Stockholm.,INSERM U1116, Université de Lorraine, Centre Hospitalier Régional Universitaire de Nancy, Vandoeuvre les Nancy, France
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany.,Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne 42055, France.,INSERM, UMR1059, Université Jean-Monnet, Saint-Etienne 42055, France.,INSERM, CIC-1408, CHU de Saint-Etienne, Saint-Etienne 42055, France.,INNOVTE, CHU de Saint-Etienne, Saint-Etienne 42055, France
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Jørn Carlsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marion Delcroix
- Clinical Dept. of Respiratory Diseases, Pulmonary Hypertension Center, UZ Leuven, Leuven, Belgium.,BREATHE, Dept CHROMETA, KU Leuven, Leuven, Belgium
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Menno V Huisman
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Luis Jara-Palomares
- Medical Surgical Unit of Respiratory Diseases, Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Rocio, Seville, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Greece
| | - Irene Lang
- Department of Internal Medicine II, Cardiology and Center of Cardiovascular Medicine, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | - Guy Meyer
- Respiratory Medicine Department, Hôpital Européen Georges Pompidou, Aphp, Paris, France.,Université Paris Descartes, Paris 75006, France
| | - Fionnuala Ní Áinle
- Dept. of Hematology, Mater University Hospital and Rotunda Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Stephan Rosenkranz
- Dept. of Cardiology, Heart Center at the University of Cologne, Germany.,Cologne Cardiovascular Research Center (CCRC), University of Cologne, Köln 50937, Germany
| | - Piotr Pruszczyk
- Dept. of Internal Medicine and Cardiology Medical University of Warsaw, Lindley St 4, Warsaw 00-005, Poland
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Naeije R, Richter MJ, Rubin LJ. The physiologic basis of pulmonary arterial hypertension. Eur Respir J 2021; 59:13993003.02334-2021. [PMID: 34737219 PMCID: PMC9203839 DOI: 10.1183/13993003.02334-2021] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/18/2021] [Indexed: 11/05/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare dyspnea-fatigue syndrome caused by a progressive increase in pulmonary vascular resistance (PVR) and eventual right ventricular (RV) failure. In spite of extensive pulmonary vascular remodeling, lung function in PAH is generally well preserved, with hyperventilation and increased physiologic dead space, but minimal changes in lung mechanics and only mild to moderate hypoxemia and hypocapnia. Hypoxemia is mainly caused by a low mixed venous PO2 from a decreased cardiac output. Hypocapnia is mainly caused by an increased chemosensitivity. Exercise limitation in PAH is cardiovascular rather than ventilatory or muscular. The extent of pulmonary vascular disease in PAH is defined by multipoint pulmonary vascular pressure-flow relationships with a correction for hematocrit. Pulsatile pulmonary vascular pressure-flow relationships in PAH allow for the assessment of RV hydraulic load. This analysis is possible either in the frequency-domain or in the time-domain. The RV in PAH adapts to increased afterload by an increased contractility to preserve its coupling to the pulmonary circulation. When this homeometric mechanism is exhausted, the RV dilates to preserve flow output by an additional heterometric mechanism. Right heart failure is then diagnosed by imaging of increased right heart dimensions and clinical systemic congestion signs and symptoms. The coupling of the RV to the pulmonary circulation is assessed by the ratio of end-systolic to arterial elastances, but these measurements are difficult. Simplified estimates of RV-PA coupling can be obtained by magnetic resonance or echocardiographic imaging of ejection fraction.
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Affiliation(s)
| | - Manuel J Richter
- Department of Internal Medicine, Justus Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Lewis J Rubin
- University of California, San Diego, La Jolla, CA, USA
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32
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Kearney K, Gold J, Corrigan C, Dhital K, Boshell D, Haydock D, McGiffin D, Wilson M, Collins N, Cordina R, Dwyer N, Feenstra J, Lavender M, Wrobel J, Whitford H, Williams T, Keating D, Whyte K, McWilliams T, Keogh A, Strange G, Kotlyar E, Anderson J, Lau EM. Chronic thromboembolic pulmonary hypertension in Australia and New Zealand: An analysis of the PHSANZ registry. Respirology 2021; 26:1171-1180. [PMID: 34608706 DOI: 10.1111/resp.14162] [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: 12/11/2020] [Revised: 07/29/2021] [Accepted: 09/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious condition occurring in 2%-4% of patients after acute pulmonary embolism. Pulmonary endarterectomy (PEA) is a potential cure for technically operable disease. The epidemiology and long-term outcomes of CTEPH have not been previously described in Australia and New Zealand. METHODS Data were extracted from the Pulmonary Hypertension Society of Australia and New Zealand (PHSANZ) registry for patients diagnosed with CTEPH between January 2004 and March 2020. Baseline characteristics, treatment strategies, outcome data and long-term survival are reported. RESULTS A total of 386 patients were included with 146 (37.8%) undergoing PEA and 240 (62.2%) in the non-PEA group. PEA patients were younger (55 ± 16 vs. 62 ± 16 years, p < 0.001) with higher baseline 6-min walk distance (6MWD; 405 ± 122 vs. 323 ± 146 m, p = 0.021), whilst both groups had similar baseline pulmonary haemodynamics. Pulmonary hypertension-specific therapy was used in 54% of patients post-PEA and 88% in the non-PEA group. The 1-, 3- and 5-year survival rates were 93%, 87% and 84% for the PEA group compared to 86%, 73% and 62%, respectively, for the non-PEA group (p < 0.001). Multivariate survival analysis showed baseline 6MWD was an independent predictor of survival in both operated and medically managed patients. CONCLUSION In this first multicentre report of CTEPH in Australia and New Zealand, long-term survival is comparable to that in other contemporary CTEPH registries. However, PEA was only performed in a minority of CTEPH patients (37.8%) and significantly less than overseas reports. Greater awareness of PEA and improved patient access to experienced CTEPH centres are important priorities.
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Affiliation(s)
- Katherine Kearney
- Heart and Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Joshua Gold
- Liverpool Hospital, Sydney, New South Wales, Australia
| | - Carolyn Corrigan
- Heart and Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - Kumud Dhital
- Heart and Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - David Boshell
- Medical Imaging Department, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - David Haydock
- Greenlane Cardiothoracic Surgical Unit, Auckland City Hospital, Auckland, New Zealand
| | - David McGiffin
- Cardiothoracic Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Michael Wilson
- Macquarie University Hospital, Sydney, New South Wales, Australia
| | | | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Nathan Dwyer
- Cardiology Department, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - John Feenstra
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Melanie Lavender
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jeremy Wrobel
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia.,School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Helen Whitford
- Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Trevor Williams
- Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Dominic Keating
- Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Ken Whyte
- Respiratory Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Tanya McWilliams
- Respiratory Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Anne Keogh
- Heart and Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Geoff Strange
- School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Eugene Kotlyar
- Heart and Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - James Anderson
- Respiratory Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Edmund Mt Lau
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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33
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Ebrahimi BS, Tawhai MH, Kumar H, Burrowes KS, Hoffman EA, Wilsher ML, Milne D, Clark AR. A computational model of contributors to pulmonary hypertensive disease: impacts of whole lung and focal disease distributions. Pulm Circ 2021; 11:20458940211056527. [PMID: 34820115 PMCID: PMC8607494 DOI: 10.1177/20458940211056527] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 10/01/2021] [Indexed: 11/29/2022] Open
Abstract
Pulmonary hypertension has multiple etiologies and so can be difficult to diagnose, prognose, and treat. Diagnosis is typically made via invasive hemodynamic measurements in the main pulmonary artery and is based on observed elevation of mean pulmonary artery pressure. This static mean pressure enables diagnosis, but does not easily allow assessment of the severity of pulmonary hypertension, nor the etiology of the disease, which may impact treatment. Assessment of the dynamic properties of pressure and flow data obtained from catheterization potentially allows more meaningful assessment of the strain on the right heart and may help to distinguish between disease phenotypes. However, mechanistic understanding of how the distribution of disease in the lung leading to pulmonary hypertension impacts the dynamics of blood flow in the main pulmonary artery and/or the pulmonary capillaries is lacking. We present a computational model of the pulmonary vasculature, parameterized to characteristic features of pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension to help understand how the two conditions differ in terms of pulmonary vascular response to disease. Our model incorporates key features known to contribute to pulmonary vascular function in health and disease, including anatomical structure and multiple contributions from gravity. The model suggests that dynamic measurements obtained from catheterization potentially distinguish between distal and proximal vasculopathy typical of pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. However, the model suggests a non-linear relationship between these data and vascular structural changes typical of pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension which may impede analysis of these metrics to distinguish between cohorts.
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Affiliation(s)
| | - Merryn H. Tawhai
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Haribalan Kumar
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Kelly S. Burrowes
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Eric A. Hoffman
- Department of Radiology, University of Iowa, Iowa City, IA,
USA
| | - Margaret L. Wilsher
- Respiratory Services, Auckland City Hospital, Auckland, New Zealand
- Faculty of Medical and Health Sciences, University of Auckland,
Auckland, New Zealand
| | - David Milne
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Alys R. Clark
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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34
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Blanquez-Nadal M, Piliero N, Guillien A, Doutreleau S, Salvat M, Thony F, Pison C, Augier C, Bouvaist H, Aguilaniu B, Degano B. Exercise hyperventilation and pulmonary gas exchange in chronic thromboembolic pulmonary hypertension: Effects of balloon pulmonary angioplasty. J Heart Lung Transplant 2021; 41:70-79. [PMID: 34742646 DOI: 10.1016/j.healun.2021.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/25/2021] [Accepted: 09/14/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Excessive ventilation (V̇E) and abnormal gas exchange during exercise are features of chronic thromboembolic pulmonary hypertension (CTEPH). In selected CTEPH patients, balloon pulmonary angioplasty (BPA) improves symptoms and exercise capacity. How BPA affects exercise hyperventilation and gas exchange is poorly understood. METHODS In this longitudinal observational study, symptom-limited cardiopulmonary exercise tests and carbon monoxide lung diffusion (DLCO) were performed before and after BPA (interval, mean (SD): 3.1 (2.4) months) in 36 CTEPH patients without significant cardiac and/or pulmonary comorbidities. RESULTS Peak work rate improved by 20% after BPA whilst V̇E at peak did not change despite improved ventilatory efficiency (lower V̇E with respect to CO2 output [V̇CO2]). At the highest identical work rate pre- and post-BPA (75 (30) watts), V̇E and alveolar-arterial oxygen gradient (P(Ai-a)O2) decreased by 17% and 19% after BPA, respectively. The physiological dead space fraction of tidal volume (VD/VT), calculated from measurements of arterial and mixed expired CO2, decreased by 20%. In the meantime, DLCO did not change. The best correlates of P(Ai-a)O2 measured at peak exercise were physiological VD/VT before BPA and DLCO after BPA. CONCLUSIONS Ventilatory efficiency, physiological VD/VT, and pulmonary gas exchange improved after BPA. The fact that DLCO did not change suggests that the pulmonary capillary blood volume and probably the true alveolar dead space were unaffected by BPA. The correlation between DLCO measured before BPA and P(Ai-a)O2 measured after BPA suggests that DLCO may provide an easily accessible marker to predict the response to BPA in terms of pulmonary gas exchange.
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Affiliation(s)
- Mathilde Blanquez-Nadal
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France
| | - Nicolas Piliero
- Service de Cardiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Alicia Guillien
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Épidemiologie environnementale appliquée à la reproduction et à la santé respiratoire, INSERM, CNRS, Université Grenoble Alpes, Institut pour l'Avancée des Biosciences (IAB), Grenoble, France
| | - Stéphane Doutreleau
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France; Laboratoire HP2, INSERM U1042, Université Grenoble Alpes, Grenoble, France
| | - Muriel Salvat
- Service de Cardiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Frédéric Thony
- Pole Imagerie, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Christophe Pison
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France
| | - Caroline Augier
- Service de Cardiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Hélène Bouvaist
- Service de Cardiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Bernard Aguilaniu
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France
| | - Bruno Degano
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France; Laboratoire HP2, INSERM U1042, Université Grenoble Alpes, Grenoble, France.
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35
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Genty T, Wirth C, Humbert M, Fadel E, Stéphan F. Pulmonary Endarterectomy in Patients With Myeloproliferative Neoplasms. Chest 2021; 161:552-556. [PMID: 34537187 DOI: 10.1016/j.chest.2021.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 08/23/2021] [Accepted: 09/09/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Thibaut Genty
- Cardiothoracic Intensive Care Unit, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Camille Wirth
- Cardiothoracic Intensive Care Unit, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Marc Humbert
- University Paris-Saclay, Faculty of Medicine, Le Plessis-Robinson, France; INSERM U999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension Reference Center of Hôpital Bicêtre, Kremlin-Bicêtre, France
| | - Elie Fadel
- University Paris-Saclay, Faculty of Medicine, Le Plessis-Robinson, France; INSERM U999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - François Stéphan
- Cardiothoracic Intensive Care Unit, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; University Paris-Saclay, Faculty of Medicine, Le Plessis-Robinson, France; INSERM U999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension Reference Center of Hôpital Bicêtre, Kremlin-Bicêtre, France.
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36
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Lang IM, Thurner S. Computer modeling to predict balloon pulmonary angioplasty success. Am J Physiol Heart Circ Physiol 2021; 321:H567-H568. [PMID: 34415190 DOI: 10.1152/ajpheart.00356.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Irene M Lang
- Department of Internal Medicine II, Cardiology, Medical University of Vienna, Vienna, Austria.,Section for Science of Complex Systems, CeMSIIS, Medical University of Vienna, Vienna, Austria
| | - Stefan Thurner
- Department of Internal Medicine II, Cardiology, Medical University of Vienna, Vienna, Austria.,Section for Science of Complex Systems, CeMSIIS, Medical University of Vienna, Vienna, Austria
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37
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Gerges C, Friewald R, Gerges M, Shafran I, Sadushi-Koliçi R, Skoro-Sajer N, Moser B, Taghavi S, Klepetko W, Lang IM. Efficacy and Safety of Percutaneous Pulmonary Artery Subtotal Occlusion and Chronic Total Occlusion Intervention in Chronic Thromboembolic Pulmonary Hypertension. Circ Cardiovasc Interv 2021; 14:e010243. [PMID: 34266313 DOI: 10.1161/circinterventions.120.010243] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Christian Gerges
- Department of Internal Medicine II, Division of Cardiology (C.G., M.G., I.S., R.S.-K., N.S.-S., I.M.L.), Medical University of Vienna, Austria
| | - Richard Friewald
- Department of Internal Medicine I, Division of Cardiology, University Hospital of Krems, Karl Landsteiner Private University for Health Sciences, Krems an der Donau, Austria (R.F.)
| | - Mario Gerges
- Department of Internal Medicine II, Division of Cardiology (C.G., M.G., I.S., R.S.-K., N.S.-S., I.M.L.), Medical University of Vienna, Austria
| | - Inbal Shafran
- Department of Internal Medicine II, Division of Cardiology (C.G., M.G., I.S., R.S.-K., N.S.-S., I.M.L.), Medical University of Vienna, Austria
| | - Roela Sadushi-Koliçi
- Department of Internal Medicine II, Division of Cardiology (C.G., M.G., I.S., R.S.-K., N.S.-S., I.M.L.), Medical University of Vienna, Austria
| | - Nika Skoro-Sajer
- Department of Internal Medicine II, Division of Cardiology (C.G., M.G., I.S., R.S.-K., N.S.-S., I.M.L.), Medical University of Vienna, Austria
| | - Bernhard Moser
- Department of Surgery, Division of Thoracic Surgery (B.M., S.T., W.K.), Medical University of Vienna, Austria
| | - Shahrokh Taghavi
- Department of Surgery, Division of Thoracic Surgery (B.M., S.T., W.K.), Medical University of Vienna, Austria
| | - Walter Klepetko
- Department of Surgery, Division of Thoracic Surgery (B.M., S.T., W.K.), Medical University of Vienna, Austria
| | - Irene M Lang
- Department of Internal Medicine II, Division of Cardiology (C.G., M.G., I.S., R.S.-K., N.S.-S., I.M.L.), Medical University of Vienna, Austria
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38
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Delcroix M, Torbicki A, Gopalan D, Sitbon O, Klok FA, Lang I, Jenkins D, Kim NH, Humbert M, Jais X, Vonk Noordegraaf A, Pepke-Zaba J, Brénot P, Dorfmuller P, Fadel E, Ghofrani HA, Hoeper MM, Jansa P, Madani M, Matsubara H, Ogo T, Grünig E, D'Armini A, Galie N, Meyer B, Corkery P, Meszaros G, Mayer E, Simonneau G. ERS statement on chronic thromboembolic pulmonary hypertension. Eur Respir J 2021; 57:13993003.02828-2020. [PMID: 33334946 DOI: 10.1183/13993003.02828-2020] [Citation(s) in RCA: 269] [Impact Index Per Article: 89.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/05/2020] [Indexed: 12/25/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism, either symptomatic or not. The occlusion of proximal pulmonary arteries by fibrotic intravascular material, in combination with a secondary microvasculopathy of vessels <500 µm, leads to increased pulmonary vascular resistance and progressive right heart failure. The mechanism responsible for the transformation of red clots into fibrotic material remnants has not yet been elucidated. In patients with pulmonary hypertension, the diagnosis is suspected when a ventilation/perfusion lung scan shows mismatched perfusion defects, and confirmed by right heart catheterisation and vascular imaging. Today, in addition to lifelong anticoagulation, treatment modalities include surgery, angioplasty and medical treatment according to the localisation and characteristics of the lesions.This statement outlines a review of the literature and current practice concerning diagnosis and management of CTEPH. It covers the definitions, diagnosis, epidemiology, follow-up after acute pulmonary embolism, pathophysiology, treatment by pulmonary endarterectomy, balloon pulmonary angioplasty, drugs and their combination, rehabilitation and new lines of research in CTEPH.It represents the first collaboration of the European Respiratory Society, the International CTEPH Association and the European Reference Network-Lung in the pulmonary hypertension domain. The statement summarises current knowledge, but does not make formal recommendations for clinical practice.
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Affiliation(s)
- Marion Delcroix
- Clinical Dept of Respiratory Diseases, Pulmonary Hypertension Center, UZ Leuven, Leuven, Belgium .,BREATHE, Dept CHROMETA, KU Leuven, Leuven, Belgium.,Co-chair
| | - Adam Torbicki
- Dept of Pulmonary Circulation, Thrombo-embolic Diseases and Cardiology, Center of Postgraduate Medical Education, ECZ-Otwock, Otwock, Poland.,Section editors
| | - Deepa Gopalan
- Dept of Radiology, Imperial College Hospitals NHS Trusts, London, UK.,Section editors
| | - Olivier Sitbon
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Frederikus A Klok
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Section editors
| | - Irene Lang
- Medical University of Vienna, Vienna, Austria.,Section editors
| | - David Jenkins
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK.,Section editors
| | - Nick H Kim
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA, USA.,Section editors
| | - Marc Humbert
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Xavier Jais
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Section editors
| | - Joanna Pepke-Zaba
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK.,Section editors
| | - Philippe Brénot
- Marie Lannelongue Hospital, Paris-South University, Le Plessis Robinson, France
| | - Peter Dorfmuller
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,Dept of Pneumology, Kerckhoff-Clinic Bad Nauheim, Bad Nauheim, Germany
| | - Elie Fadel
- Hannover Medical School, Hannover, Germany
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,Dept of Pneumology, Kerckhoff-Clinic Bad Nauheim, Bad Nauheim, Germany
| | | | - Pavel Jansa
- 2nd Department of Medicine, Dept of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Michael Madani
- Sulpizio Cardiovascular Centre, University of California, San Diego, CA, USA
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Takeshi Ogo
- National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Ekkehard Grünig
- Thoraxklinik Heidelberg at Heidelberg University Hospital, Heidelberg, Germany
| | - Andrea D'Armini
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | | | - Bernhard Meyer
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | | | | | - Eckhard Mayer
- Dept of Thoracic Surgery, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany.,Equal contribution.,Co-chair
| | - Gérald Simonneau
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Equal contribution.,Co-chair
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39
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Gerges C, Lang I. A multiparametric approach for the assessment of prognosis in pulmonary hypertension after pulmonary endarterectomy - stratifying risk in a poorly-defined condition. Int J Cardiol 2021; 337:101-102. [PMID: 34000357 DOI: 10.1016/j.ijcard.2021.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/10/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Christian Gerges
- Department of Internal Medicine II, Division of Cardiology, Vienna General Hospital, Medical University of Vienna, Austria.
| | - Irene Lang
- Department of Internal Medicine II, Division of Cardiology, Vienna General Hospital, Medical University of Vienna, Austria
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40
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Wang TM, Wang SS, Xu YJ, Zhao CM, Qiao XH, Yang CX, Liu XY, Yang YQ. SOX17 Loss-of-Function Mutation Underlying Familial Pulmonary Arterial Hypertension. Int Heart J 2021; 62:566-574. [PMID: 33952808 DOI: 10.1536/ihj.20-711] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Pulmonary arterial hypertension (PAH) refers to a rare, progressive disorder that is characterized by occlusive pulmonary vascular remodeling, resulting in increased pulmonary arterial pressure, right-sided heart failure, and eventual death. Emerging evidence from genetic investigations of pediatric-onset PAH highlights the strong genetic basis underpinning PAH, and deleterious variants in multiple genes have been found to cause PAH. Nevertheless, PAH is of substantial genetic heterogeneity, and the genetic defects underlying PAH in the overwhelming majority of cases remain elusive. In this investigation, a consanguineous family suffering from PAH transmitted as an autosomal-dominant trait was identified. Through whole-exome sequencing and bioinformatic analyses as well as Sanger sequencing analyses of the PAH family, a novel heterozygous SOX17 mutation, NM_022454.4: c.379C>T; p. (Gln127*), was found to co-segregate with the disease in the family, with complete penetrance. The nonsense mutation was neither observed in 612 unrelated healthy volunteers nor retrieved in the population genetic databases encompassing the Genome Aggregation Database, the Exome Aggregation Consortium database, and the Single Nucleotide Polymorphism database. Biological analyses using a dual-luciferase reporter assay system revealed that the Gln127*-mutant SOX17 protein lost the ability to transcriptionally activate its target gene NOTCH1. Moreover, the Gln127*-mutant SOX17 protein exhibited no inhibitory effect on the function of CTNNB1-encode β-catenin, which is a key player in vascular morphogenesis. This research firstly links SOX17 loss-of-function mutation to familial PAH, which provides novel insight into the molecular pathogenesis of PAH, suggesting potential implications for genetic and prognostic risk evaluation as well as personalized prophylaxis of the family members affected with PAH.
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Affiliation(s)
- Tian-Ming Wang
- Department of Pediatrics, Tongji Hospital, Tongji University School of Medicine
| | - Shan-Shan Wang
- Department of Pediatrics, Tongji Hospital, Tongji University School of Medicine
| | - Ying-Jia Xu
- Department of Cardiology, Shanghai Fifth People's Hospital, Fudan University
| | - Cui-Mei Zhao
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine
| | - Xiao-Hui Qiao
- Department of Pediatric Internal Medicine, Ningbo Women & Children's Hospital
| | - Chen-Xi Yang
- Department of Cardiology, Shanghai Fifth People's Hospital, Fudan University
| | - Xing-Yuan Liu
- Department of Pediatrics, Tongji Hospital, Tongji University School of Medicine
| | - Yi-Qing Yang
- Department of Cardiology, Shanghai Fifth People's Hospital, Fudan University.,Cardiovascular Research Laboratory, Shanghai Fifth People's Hospital, Fudan University.,Central Laboratory, Shanghai Fifth People's Hospital, Fudan University
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41
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Ghio S, Klersy C, Corsico A, Gamba SL, Monterosso C, Masiglat J, Borrelli E, Scelsi L, Greco A, Piloni D, Visconti LO, D'Armini AM. Risk stratification in patients with residual pulmonary hypertension after pulmonary endarterectomy. Int J Cardiol 2021; 334:116-122. [PMID: 33823214 DOI: 10.1016/j.ijcard.2021.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/06/2021] [Accepted: 04/02/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Few studies addressed the issue of risk stratification in patients with residual pulmonary hypertension (PH) after pulmonary endarterectomy (PEA). This study tested the potential added value of parameters that have not been included in existing risk models. METHODS We evaluated 546 consecutive patients with chronic thromboembolic pulmonary hypertension who underwent PEA and were followed-up for a median period of 58 months. RESULTS Among the 242 with residual PH, 27 died and had 127 a clinical worsening event. At univariable analysis, the parameters associated with poor survival were pulmonary vascular resistance (PVR) ≥425 dyn·s·cm-5 (p ≤ 0.001), mean pulmonary artery pressure (mPAP) ≥38 mmHg (p = 0.003) and pulmonary artery compliance (CPA) ≤1.8 ml/mmHg (p = 0.014). In the bivariable models including either PVR or mPAP as first parameter, the addition of CPA was not statistically significant. The parameters associated with poor clinical worsening were CPA ≤1.8 ml/mmHg (p < 0.001), PVR ≥425 dyn·s·cm-5 (p = 0.002), arterial oxygen tension (PaO2) ≤ 75 mmHg (p = 0.003), mPAP ≥38 mmHg (p = 0.008). In a multivariable analysis which included PVR ≥425 as the first parameter, the addition of both CPA ≤1.8 ml/mmHg and of PaO2 ≤ 75 mmHg significantly improved prognostic stratification (Harrel's C of the model = 0.64, p < 0.001). Noticeably, the lower tertile of the model's predictor index identified a subgroup of 91 patients who had an event rate numerically similar to that of patients without residual PH. CONCLUSIONS Risk stratification in residual PH can be refined if CPA and PaO2 are considered in association with standard hemodynamic parameters.
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Affiliation(s)
- Stefano Ghio
- Division of Cardiology, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy.
| | - Catherine Klersy
- Service of Clinical Epidemiology & Biometry, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy
| | - Angelo Corsico
- Division of Respiratory Diseases, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy
| | - Sofia Lucia Gamba
- Division of Cardiac Surgery, Cardiopulmonary Surgery and Pulmonary Hypertension, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy
| | - Cristian Monterosso
- Division of Cardiac Surgery, Cardiopulmonary Surgery and Pulmonary Hypertension, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy
| | - Joice Masiglat
- Department of Surgical, Clinical, Diagnostic and Pediatric Sciences, University of Pavia School of Medicine, Pavia, Italy
| | - Ermelinda Borrelli
- Department of Surgical, Clinical, Diagnostic and Pediatric Sciences, University of Pavia School of Medicine, Pavia, Italy
| | - Laura Scelsi
- Division of Cardiology, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy
| | - Alessandra Greco
- Division of Cardiology, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy
| | - Davide Piloni
- Division of Respiratory Diseases, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy
| | | | - Andrea Maria D'Armini
- Division of Cardiac Surgery, Cardiopulmonary Surgery and Pulmonary Hypertension, Foundation "I.R.C.C.S. Policlinico San Matteo", Pavia, Italy; Department of Surgical, Clinical, Diagnostic and Pediatric Sciences, University of Pavia School of Medicine, Pavia, Italy
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42
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Yang X, Zhang L, Ye JQ, Wu XH, Zeng XX, Chen LW, Li YM. The role of ATG-7 contributes to pulmonary hypertension by impacting vascular remodeling. J Mol Cell Cardiol 2021; 157:1-13. [PMID: 33819456 DOI: 10.1016/j.yjmcc.2021.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/07/2021] [Accepted: 03/24/2021] [Indexed: 12/24/2022]
Abstract
AIM Pulmonary hypertension (PH) is a pathophysiological syndrome with functional abnormalities of the pulmonary artery and heart, eventually becoming life threatening to the patients. Autophagy-related gene 7 (ATG)-7 is involved in many cardiovascular diseases, but little is known about the specific role of ATG-7 in the development of PH. We aimed to examine the expression of ATG-7 in PH patients and PH mice, specifically investigate pulmonary physiological responses in a mouse model with conditional deletion of ATG-7 in smooth muscle cells (SMCs) and further clarify the mechanism of PH caused by ATG-7 deficiency. METHODS AND RESULTS SMC-ATG-7-/- mice underwent echocardiography and subsequent pulmonary arterial pressure (PAP) checks. The PAP was lower in wild-type (WT) mice (22.6 ± 2.0 mmHg) than knockout (KO) mice (34.0 ± 2.5 mmHg; p < 0.001). Pulmonary artery resistance was increased in KO (17.61 ± 2.03 mm2·s-1) versus WT mice (8.91 ± 1.62 mm2·s-1; p < 0.005). Combined with these statistics, SMC-ATG7-/- mice were diagnosed with PH. The increase of ATG-7 expression in vessels from PH patients and PH mice were assessed and the effects of ATG-7 on vascular remodeling were investigated in SMCs using relevant methods. We also identified silencing ATG-7 in SMCs induced the increased level of Ca2+ and abnormal proliferation through PP2A/ 4EBP-1/ elf-4E pathway. CONCLUSIONS ATG-7 affects vascular remodeling and exerts a protective function during the pathogenesis of PH. Our study revealed a novel mechanism ATG-7 deficiency promotes cell proliferation via the interaction between PP2A, 4EBP-1 and elf-4E.
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Affiliation(s)
- Xi Yang
- School of Pharmacy, Fujian Medical University, Fuzhou 350122, China; Department of Toxicology, Fujian Center for Evaluation of New Drug, Fujian Medical University, Fuzhou, China
| | - Li Zhang
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China; The Key Laboratory of Fujian Province University on Ion Channel and Signal Transduction in Cardiovascular Disease, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China; Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Jian-Qiang Ye
- School of Pharmacy, Fujian Medical University, Fuzhou 350122, China; Department of Toxicology, Fujian Center for Evaluation of New Drug, Fujian Medical University, Fuzhou, China
| | - Xiao-Hui Wu
- School of Pharmacy, Fujian Medical University, Fuzhou 350122, China; Department of Toxicology, Fujian Center for Evaluation of New Drug, Fujian Medical University, Fuzhou, China
| | - Xi-Xi Zeng
- The Key Laboratory of Fujian Province University on Ion Channel and Signal Transduction in Cardiovascular Disease, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China; Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Liang-Wan Chen
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
| | - Yu-Mei Li
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of Toxicology, Fujian Center for Evaluation of New Drug, Fujian Medical University, Fuzhou, China; Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China.
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Zhou XL, Huang FJ, Li Y, Huang H, Wu QC. SEDT2/METTL14-mediated m6A methylation awakening contributes to hypoxia-induced pulmonary arterial hypertension in mice. Aging (Albany NY) 2021; 13:7538-7548. [PMID: 33658391 PMCID: PMC7993666 DOI: 10.18632/aging.202616] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 08/08/2020] [Indexed: 12/11/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a fatal disease whose molecular mechanism is unknown. The trimethylation of lysine 36 on histone 3 (H3K36me3) catalyzed by SETD2 and the modification of N6-methyladenine (m6A) mRNA mediated by METTL14 play important roles in a variety of normal and pathological biological processes. However, the role of these epigenetic controls in the pathogenesis of PAH remains unclear. In this study, the expression of SETD2 and METTL14 was elevated in pulmonary artery smooth muscle cells (PASMCs) of hypoxia-induced PAH mice. We further constructed a mouse model with SETD2 specific knockout in smooth muscle cells (SETD2SM22α Cre). Our results suggest that the lack of SETD2 in SMCs protected mice from hypoxia-induced PAH and significantly reduced right ventricular systolic pressure (RVSP), right ventricular/left ventricular plus septum [RV/(LV+S)] weight ratio, and pulmonary median width. In addition, the absence of SETD2 in SMCs alleviates the level of METTL14 expression and the m6A RNA methylation level in PAH SMCs. These results obtained from mice suggest that strategies that target the inhibition of SETD2/METTL14 activity may be a viable treatment for PAH in a clinical setting.
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Affiliation(s)
- Xue-Liang Zhou
- Department of Cardiac Surgery, The First Affiliated Hospital, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Feng-Jian Huang
- Department of Cardiac Surgery, The First Affiliated Hospital, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Yang Li
- Department of Cardiac Surgery, The First Affiliated Hospital, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Huang Huang
- Department of Cardiac Surgery, The First Affiliated Hospital, Nanchang University, Nanchang 330006, Jiangxi, China
| | - Qi-Cai Wu
- Department of Cardiac Surgery, The First Affiliated Hospital, Nanchang University, Nanchang 330006, Jiangxi, China
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) and chronic thromboembolic pulmonary vascular disease (CTED) are rare manifestations of venous thromboembolism. Presumably, CTEPH and CTED are variants of the same pathophysiological mechanism. CTEPH and CTED can be near-cured by pulmonary endarterectomy, balloon pulmonary angioplasty, and medical treatment with Riociguat or subcutaneous treprostinil, which are the approved drugs.
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Andersen A, van der Feen DE, Andersen S, Schultz JG, Hansmann G, Bogaard HJ. Animal models of right heart failure. Cardiovasc Diagn Ther 2020; 10:1561-1579. [PMID: 33224774 PMCID: PMC7666958 DOI: 10.21037/cdt-20-400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/13/2020] [Indexed: 12/17/2022]
Abstract
Right heart failure may be the ultimate cause of death in patients with acute or chronic pulmonary hypertension (PH). As PH is often secondary to other cardiovascular diseases, the treatment goal is to target the underlying disease. We do however know, that right heart failure is an independent risk factor, and therefore, treatments that improve right heart function may improve morbidity and mortality in patients with PH. There are no therapies that directly target and support the failing right heart and translation from therapies that improve left heart failure have been unsuccessful, with the exception of mineralocorticoid receptor antagonists. To understand the underlying pathophysiology of right heart failure and to aid in the development of new treatments we need solid animal models that mimic the pathophysiology of human disease. There are several available animal models of acute and chronic PH. They range from flow induced to pressure overload induced right heart failure and have been introduced in both small and large animals. When initiating new pre-clinical or basic research studies it is key to choose the right animal model to ensure successful translation to the clinical setting. Selecting the right animal model for the right study is hence important, but may be difficult due to the plethora of different models and local availability. In this review we provide an overview of the available animal models of acute and chronic right heart failure and discuss the strengths and limitations of the different models.
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Affiliation(s)
- Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Diederik E. van der Feen
- Center for Congenital Heart Diseases, University Medical Center Groningen, Groningen, The Netherlands
| | - Stine Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Harm Jan Bogaard
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Abstract
PURPOSE OF REVIEW The present review provides an update on treatment of chronic thromboembolic pulmonary hypertension (CTEPH), a rare form of pulmonary hypertension characterized by precapillary pulmonary hemodynamic parameters with chronic thrombotic occlusion of the pulmonary vasculature. RECENT FINDINGS Pulmonary thromboendarectomy (PTE) remains the recommended treatment for patients with surgically accessible disease. Recent data suggest that patients preoperatively bridged with medical therapy may have improved outcomes but further research is needed. Riociguat improves hemodynamics, right ventricular function, quality of life, and functional capacity and is the drug of choice for patients with inoperable/persistent disease. Recently published data suggest that endothelin receptor blockers and treprostinil may also have a role in medical management of this patient population. A growing body of evidence indicates that in experienced centers balloon pulmonary angioplasty (BPA) may be a well tolerated and effective adjunct to pharmacological treatment for patients with inoperable disease affecting subsegmental vasculature. SUMMARY Untreated CTEPH carries significant morbidity and mortality. Recent publications provide a wealth of data on safety and efficacy of BPA for inoperable subsegmental disease, but its precise fit in the treatment algorithm, both pharmacological and procedural, requires further investigation. PTE remains the procedure of choice for surgically accessible disease.
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Gerges M, Yacoub M. Chronic thromboembolic pulmonary hypertension - still evolving. Glob Cardiol Sci Pract 2020; 2020:e202011. [PMID: 33150155 PMCID: PMC7590968 DOI: 10.21542/gcsp.2020.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is one of the leading causes of severe pulmonary hypertension (PH). The disease is still underdiagnosed, and the true prevalence is unknown. CTEPH is characterized by intraluminal non-resolving thrombus organization and fibrous stenosis, or complete obliteration of pulmonary arteries, promoted by progressive remodeling of the pulmonary vasculature. One consequence of this is an increase in pulmonary vascular resistance and pressure, resulting in PH and progressive right heart failure, leading to death if left untreated. Endovascular disobliteration by pulmonary endarterectomy (PEA) is the preferred treatment for CTEPH patients. PEA surgery is the only technique that can potentially cure CTEPH disease, especially in patients with fresh or organized thrombi of the proximal branches of pulmonary arteries. However, not all patients are eligible for PEA surgery. Recent research has provided evidence suggesting balloon pulmonary angioplasty (BPA) and targeted medical therapy as additional promising available treatments options for inoperable CTEPH and recurrent/persistent PH after PEA surgery. Studies on BPA have shown it to improve pulmonary hemodynamics, symptoms, exercise capacity and RV function in inoperable CTEPH. Subsequently, BPA has developed into an essential component of the modern era of CTEPH treatment. Large randomized controlled trials have demonstrated varying significant improvements with targeted medical therapy in technically inoperable CTEPH patients. Thus, treatment of CTEPH requires a comprehensive multidisciplinary assessment, including an experienced PEA surgeon, PH specialist, BPA interventionist and CTEPH-trained radiologist at expert centers. In this comprehensive review, we address the latest developments in the fast-evolving field of CTEPH. These include advancements in imaging modalities and developments in operative and interventional techniques, which have widened the range of patients who may benefit from these procedures. The efficacy and safety of targeted medical therapies in CTEPH patients are also discussed. As the treatment options for CTEPH improve, hybrid management involving multiple treatments in the same patient may become a viable option in the near future.
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Affiliation(s)
- Mario Gerges
- Department of Internal Medicine II, Division of Cardiology, General Hospital Vienna, Medical University of Vienna, Vienna, Austria
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